Hello and welcome. I'm Shireen Khan, Vice President of Operations and Strategy at Thresholds, Illinois' oldest and largest provider of community mental health services, and I'm also a social work expert for SMI Advisor. I'm pleased that you're joining us for today's SMI Advisor webinar, An Introduction to Affirmative Practices for Transgender and Non-Binary Clients with Serious Mental Illness. Next slide, please. SMI Advisor, also known as the Clinical Support System for Serious Mental Illness, is an APA and SAMHSA initiative devoted to helping clinicians implement evidence-based care for those living with serious mental illness. Working with experts from across the SMI clinician community, our interdisciplinary effort has been designed to help you get the answers you need to care for your patients. This webinar has been designated for one AMA PRA Category 1 credit for Physicians, one Continuing Education credit for Psychologists, one Continuing Education credit for Social Workers, and credit for participating in today's webinar will be available until October 17, 2022. Slides from the presentation today are available in the handouts area found in the lower portion of your control panel. Select the link to download the PDF. Next slide. Please feel free to submit your questions throughout the presentation by typing them into the question area also found in the lower portion of your control panel. We do plan to reserve 10 to 15 minutes at the end of the presentation for Q&A. Next. Now, I'd like to introduce you to the faculty for today's webinar, Dr. Ashley Austin, Dr. Lisa Rosano, and Dr. Asher X. Dr. Lisa Rosano, PhD, CPRP, is a tenured Associate Professor of Psychiatry and Deputy Director of the Center on Mental Health Services Research and Policy at the University of Illinois at Chicago and Director for the James Scholar Program at the UIC College of Medicine. Dr. Rosano is recognized internationally for her funded research and workforce development programs focusing on mental health recovery, physical health comorbidities, mental health aspects of HIV and AIDS, and community intervention and services research. Dr. Ashley Austin is a Professor of Social Work at Berry University. Dr. Austin's research and expertise revolves primarily around developing practice-based knowledge to promote the health and well-being of transgender and gender-diverse children, teens, and adults. Her clinical practice approaches are rooted in an affirmative framework that honors sexual and gender diversity across the lifespan. As co-developer and purveyor of the AFIRM interventions, Dr. Austin is actively involved in research, training, and consulting associated with effective implementation of AFIRM across a wide range of sites both nationally and internationally. Dr. S. will share his background as a person with lived experience a little later on in the presentation. My colleague just put a link to the guide from the Center that we're partnering with today with language guidance when serving LGBT plus populations, so I encourage you to take a look. Thank you all so much for leading today's webinar. Thanks, Shereen, and I'll just say, this is Lisa Rosano starting off here, that none of the presenters today have any relevant disclosures. Listed here, you can see the learning objectives that have been approved for this presentation, and as we get started, we will continue to move across those. Okay, so starting out, we wanted to think about some of the things that people typically think about or at least consider from some constructs about what we think about sex and gender. So as we go through today's presentation, we'd like to invite everyone to think about these questions. What expectations do or did people have about us based on the gender that we were assigned at birth? How has this shaped our professional and personal development, and how do these assumptions and expectations affect us today as we not only have experienced gender as individuals, but as we continue to experience gender across the lifespan? So I just want to start with some very basic constructs in this particular presentation, but I will make a note here that SMI Advisor has a number of other presentations regarding gender identity, depending on the level of experience that individuals who you work with might have in this particular area. But when we talk about sex and gender, we come primarily from a principally dimorphic type of construct, and that is that we know genetically women or girls are born with an XX chromosome, and that chromosomally, boys and men are typically born with XY. What we do know, however, is that these XX and XY chromosomal makeups do not necessarily always result in external genitalia or phenotypic expression of the genes in a way that can be seen as clearly male or clearly female. It's also the case that a substantial or at least notable proportion of individuals are born with the classification of intersex, where it's not really particularly clear anatomically that you can make a distinction between one anatomical structure or another. So while we see or we assume this genetic and biologic dimorphism, to some degree it's not necessarily something that you can apply exclusively to humans because there are going to be some exceptions. But since it's the construct we started with biologically, we then moved to what would be a construct of behavior that would flow from those biological ideas of maleness and femaleness based on genetics or even based on anatomical structures that we see at birth or assigned at birth. These are more social and emotional types of constructs about gender, and they also include a lot of cognitive and scripted maybe ideas about what it means to be male, what it means to demonstrate that, what it means to be female, and certainly what it means to experience or demonstrate that femaleness. And so what we now have is not only a biological construct of sex, but we've now moved into what would be considered a dimorphic social construct of gender. To some degree, this wasn't really talked about for a long time until we get to the 1970s. And you see some early research by a psychologist by the name of Sandra Bem, who starts talking about a cognitive and behavioral construct of gender that leads from this principally dimorphic construct of sex. And what Bem talks about is an early discussion of these gender roles or the behavioral aspects that are assigned or attributed, if you will, to these cognitive constructs of maleness, masculinity, and femaleness, femininity. What's important about these is that these initially in this theory do come from the idea of what your anatomical or biological assignment is at birth and the degree to which that you endorse the items that have been socially and at least cognitively assigned to your sex. And so you can see here in this very colorful figure that if you're anatomically or biologically a woman and you highly endorse feminine ideas and don't endorse a lot of masculine ideas, you might be considered traditionally feminine in the pink box. Likewise, on the other side, if you're anatomically assigned to maleness and you endorse highly masculine but not a lot of feminine characteristics, you would find yourself in the masculine category. Bem really opened up a conversation beyond that, which was that people did not necessarily have to endorse one or the other. And that's probably why we still talk about this theory in gender studies today, because what she brings up is the idea that people can endorse both masculine and both feminine kinds of constructs and behaviors in their lives. And you see here on the right, there is a list of things here on the slide that are the initial constructs of what is masculine and what is feminine. And I think all of us, if we go back to those initial questions about what were the expectations people have or do have for us, how have they affected us? We can see along these lines that we've probably behaved in a way that might be considered in alignment with our gender or that might not be considered in alignment with our gender. I can disclose to you personally as a professor in the psychiatry department at the College of Medicine, I've had to endorse a lot of the masculinity items over the years in order to get by in that type of environment. So while it might be considered outside of my gender role, it has been considered a necessity in terms of my professional role in the environment that I'm in. So I bring these up for people to consider whether or not we allow people to move fluidly among these types of behaviors and why we would think of something as being analytical as exclusively masculine, or we would think of something as soft-spoken or even childlike as an adult woman. What kind of endorsement is that we have in terms of our expectations about gender? So this is a very static and compartmentalized theory, and when you look at it, it really only sets the foundation for us to consider that we can step out of these roles, that they don't necessarily mean that if you endorse one, you have to be low on the other, and it opens up the opportunity for us to experience social constructs that are either in or outside of what we would consider our gender role. Now this said, this leads us to how this affects our mental health. So without getting too much into the history of the DSM and gender, you can see on this slide a pretty basic summary of what we get in terms of classification of mental illnesses and mental disorders, which really is the goal of the DSM. The first two editions of DSM actually contain virtually no mention of gender identity. They do talk a little bit about sex and sex-related disorders. In 1980, DSM III will be the first to publish any sort of mention of what would be a characteristic of transsexualism in the paraphilias, which would not necessarily be something where we might have a construct where we discuss gender. In 1994, DSM IV does replace that with the idea of gender identity disorder in what was considered an effort to reduce stigma, but the approach to gender identity disorder was possibly one that wasn't as empowering to individuals who experienced their gender differently. So in 2013, with the release of DSM V, we see the elimination of that and the explicitness in classification that gender nonconformity is not necessarily considered a mental disorder and gender variance itself is not a form of psychopathology. Having said all of this historically, I will leave it to my very experienced clinical colleagues to talk about how this really articulates itself in clinical practice. We do know from population health studies, however, that the effects of adverse childhood experiences or ACEs and other social determinants of health are going to differentially affect gender-related or gender-experiencing populations, and what we can see in those samples are things that I don't think will surprise any of the mental health practitioners or really anyone on this broadcast. We see higher rates of anxiety among trans men and women than what you would expect in the general population, higher rates of depression. There have been some studies, but I would not necessarily consider them particularly methodologically rigorous, that do demonstrate some preliminary ideas regarding schizophrenia spectrum or autism spectrum disorders and the relationship to gender identity, and certainly other mental health and, to some degree, psychotic conditions might include aspects of gender, but they are not necessarily characteristically going to include aspects of gender identity. Then, of course, we will see that there are some consequences that are much more serious in this population. The aspects of suicidality or self-harm, and then certainly the rates of drug use and substance use that you would see among individuals who will actually say this is based to some degree or in response to gender or mistreatment they've received in their gender identity, not necessarily other risk factors that might drive substance use risk. In mental health and anxiety, depression particularly, when we compare individuals within the GLBTQ community, particularly young individuals, we also see here that within the GLBT population on sexual orientation, for youth who identify as trans or non-binary with regard to gender identity, we will see even higher rates of anxiety and depression in that subpopulation. One of the things I do like to say in pause on this slide among GLBTQ youth, which is not necessarily exclusively today's discussion, but these rates of anxiety and depression among cisgender LGBTQ people in our communities is certainly nothing to be proud of. When we look at even these elevated rates among trans and non-binary people, these are particularly alarming rates for young people to experience these types of mental disorders. Having said that, I'm going to turn things over to Dr. Austin, who will continue with our discussion. Thank you, Dr. Rossano. Welcome, everybody. Hi. I'm Ashley Austin. I'm here today. I think you heard a little bit about my bio. I'm here in my capacity as a consultant and researcher with the Center of Excellence for LGBTQ Behavioral Health Equity, and I'm really happy to be a part of this conversation and talking to all of you today because I think it's really, really, really important. On the last slide, we saw that the rates of mental health concerns are high among LGBTQ people broadly, but today we're focusing on trans and non-binary folks, and so because that's our population focus today, I'm really going to talk about one of the major factors that is relevant to trans and non-binary folks that isn't really relevant to any cisgender LGBTQ folks, and that's this idea of gender dysphoria. We just had a glimpse of what's going on with the diagnosis broadly or where trans issues have landed with respect to the DSM-5 and the DSM over time, and we're looking at it now in terms of the DSM-5, and we're going to think about it a little bit both in terms of sort of the diagnosis, but then really beyond that, we're going to look at the experience much more broadly, and so as we talked about this idea that sort of moving from gender identity disorder and this sort of pathological view, we started to move in 2013 to really understand the experience, what was this experience of gender dysphoria, and that sort of began the conversation in 2013, started to get in the right direction, and then we start to sort of dissect that a little bit more, and next slide, please. I'll sort of go into a little bit for those of you who aren't totally familiar. We'll just look at this, what it looks like, right? So when we're looking and thinking about what it looks like in the DSM-5, it looks like I'm going to highlight a couple of things, right? What the DSM focuses on is, for one, that obviously the experience that we're talking about is an incongruence between expressed or experienced gender and the gender reassigned at birth, right? Sort of what the world told us we are, and that these experiences of distress are present for at least six months, right? And so the incongruence, and they sort of give these different criteria, one through six around sort of incongruence between identity and our primary and secondary sex characteristics, a desire to be rid of our one's primary, secondary sex characteristics, and differently, a desire for primary and or secondary sex characteristics of the other gender or of another gender, right? So to include non-binary folks as well, and so there's sort of, we go through this idea that we want to be treated, and sort of this is the language that we're using, but really treated, seen as, perceived as the gender that we feel that we are, and the conviction that we have sort of the feelings or reactions of a different gender than we were assigned at birth. And so these are really important. Interestingly, clinically, most folks that I work with, well, I primarily work with, in my private practice, I see trans people, and we do this sort of as an assessment tool. Usually it's close to an all or nothing situation, right? Anybody that I'm seeing, it's sort of like they usually have five or six of these, not just a smattering, because these are sort of like flip sides of each other, and then they go kind of hand in hand, and they are important, and what I'm going to get into later is there's a lot more to this. And so the other piece at the bottom is really the piece that's in some ways the most important for me as a clinician, and as a practitioner, it's this condition, right? Because gender dysphoria is associated with clinically significant distress or impairment in social, occupational, or other important areas of functioning. And this distress is really what, in some ways, what we're talking about today and what I want to highlight for you all, so that as you're thinking about the clients that you're seeing who are presenting with various mental health concerns or major mental illness in a variety of areas, that we're really thinking about, well, how does gender dysphoria play a role, or what does this mean for trans people or non-binary people, I don't get it. And so part of the really important piece here is this idea that when we look at just the DFM, it doesn't really give us a full picture, it's a helpful checklist to sort of figure out if people are experiencing this, indeed, they're experiencing sort of this idea of this gender dysphoria, but the level and the way it impacts and intersects with other conditions, other concerns, is really, really important to sort of the everyday practice. What do we do with this? How do we help our clients feel better, live better, be better? And so that's what we're really going to sort of hone in on today. Next slide, please. And I think what we've done is we've done a little bit of work, some colleagues and I have actually done a qualitative study on looking deeply at gender dysphoria. And really, you're going to see in a minute some of the quotes that I'm sharing are from that study, we'll really get into sort of what is this experience like that goes beyond sort of this idea of the DSM criteria, right? That sort of gives us an idea of, okay, this is somebody who's not cisgender, and what does it mean to be trans and experiencing gender dysphoria, right? And so some of the other symptoms that we're looking at are sort of, they could mimic, right, look like other symptoms associated with depression or anxiety or other serious mental health concerns, and they're also really different. So these are just some examples, right? So this idea of lots of folks talking about not showering or showering in the dark, hated touching or washing their own body, dissociation that happens during bathing or bathrooming time. So this idea, burning sensation of the skin or tingling, wanting to crawl out of one's skin, avoiding mirrors, avoiding getting dressed, avoiding surfaces where I can see my reflection. Lots of feelings of either free-floating or target anxiety, feelings of depression that are sometimes very targeted, sometimes not, anger or frustration from one's body, and even more than that, a feeling often of disconnection or dissociation from one's own body, not recognizing it, not feeling like it belongs to them, to oneself, right? So having more than usual, you know, this is not on here, but also nightmares, lots and lots of nightmares or very, very disrupted sleep is also really common, as are things like hypervigilance. Sometimes it's hypervigilance about, can anyone see my chest or is it noticeable in this binder? Or hypervigilance about how are they perceiving me? What are they saying? Are they whispering about me? And these are sort of, these are really common experiences for people suffering from gender dysphoria. And gender dysphoria is an interesting conversation that could sort of span, in my opinion, of course, right? Like decades and days and days and hours, but we don't have that time, so I'm going to try to stick. You'll see me looking at my phone, stick to my time. But part of this is this idea that there is a lot, this is internal, right? This is an experience that is deeply internal and deeply visceral. And it's important to recognize it. And it's exacerbated like everything else, right? Like all of our other mental health concerns, it's exacerbated by lots and lots of different social conditions, right? Environments that are hostile or negative or transphobic are going to exact judgmental, very rigidly binary, not accepting of fluidity. These kinds of environments, whether they're in childhood or adulthood, the workplace, interpersonal partnerships, any of these are going to deeply exacerbate experiences of dysphoria and the symptoms that come along with that. And so I think it's really important to think about these things as we are thinking about working with clients who may be presenting with both gender dysphoria and a range of other diagnoses, or we're not sure what they're presenting with. We're trying to sort of differentially diagnose what's going on with our clients so we can best help them and best treat them. Next slide, please. I want to share this slide as well, because I think it's really important to look at this other piece of sort of, okay, I gave a couple like examples. This is in the words of a participant that was in our study, and really similar to what a lot of clients that I see talk about, but this really speaks about the suffering associated with this particular individual's experience of their gender dysphoria. And just to sort of give context, the question was, what is gender dysphoria like for you? Sort of that open-ended. And this person likens it to drowning, to being waterboarded, to feeling like they are suffocating and not able to breathe. And that it is sort of this idea that if someone sees them, they will turn to dust. And this sort of, we got lots and lots of really thick descriptions like this that were very, very expressive of the pain and the suffering. And in this person's, I love what they said here. It's really important sort of distinction. This person says that is gender dysphoria at its worst. And that's really important and something I try to drive home a lot to the folks I train and work with. Gender dysphoria does ebb and flow. So it won't feel like that all the time for your clients. There's an ebb and flow. So if their client is not presenting with this at every minute, it doesn't mean they don't have gender dysphoria. It is really normal for gender dysphoria to have ups and downs. It never abates on its own, but it does. It's not always at its worst, but when it's at its worst, it can be debilitating in this way. And that's something really important to think about when you're working with people, that it's expected and understandable that dysphoria will not present exactly the same each and every day that you see your client and it's still there and it's still really real. Next slide, please. This is another example. And this particular example is really useful for today's talk in that it talks about the way, again, a little bit of the ways in which dysphoria can trigger other mental health symptoms. And for this person, they're talking about the anxiety that comes with talking out loud because of the voice, how high their voice was. That's really common. We'd often think about it, but sort of having to share a voice that's really dissonant for you and doesn't match your gender identity can be excruciating for clients, really triggering social anxiety and other serious anxious conditions. This person goes on to talk about their chest and how when their chest dysphoria is really severe, it makes them sort of almost have a panic. And I've had lots of clients talk about having panic attacks associated with sort of being seen or having something noticed in a social situation or when they're outside of their house that sort of highlights their gender. And in this case, this particular person was talking about, for them, how their bottom dysphoria at this point in time, the time of the interview was really, really had displaced some of the other aspects of their dysphoria and was really causing them the most anxiety and panic. And this is really sort of common for different parts of oneself to be really salient and really problematic at certain times and for clients to feel them in different ways. But indeed, really the idea, right? This distress that's in the DSM, this is what we mean by distress. It's not like, it's a bummer. It's not like it's a bummer. It's like panic attacks. It can be like anxiety. It can feel like suffocating. It can feel like all of these things. So I think that's really important for all of us to be thinking about. Next slide, please. And this is another person, and we chose this quote because I think it's really important. It says a couple of things. This is a person who does have self-awareness, who's thinking about, I know I have depression, anxiety, and I know that it, by it, they mean their gender dysphoria. When it's really sort of, when it's really surfacing, it magnifies their depression and their anxiety. Really sort of taking the concerns that they already have, right? And really magnifying, making self-care really, really difficult. Not wanting to shave because, right? So for this person who's a trans woman, it goes back feeling this sort of hopelessness and this idea of futility and making sort of the giving up, sort of what we might see as hopelessness or someone giving up. And it's really important to tune into the self-care piece, right? This person's talking about self-care. It is super important to recognize that sometimes we might see in clients things that we might not, if we're not looking through the lens of gender dysphoria, if we're not understanding through the lens of the trans experience, we might not get that showering, that getting dressed in clothes that don't match me, that wearing clothes that, maybe they are the clothes I wanna wear and my body is not looking in them the way I need it to. So, right? These different things are happening. It makes self-care exhausting. It makes self-care excruciating. It makes folks sometimes want to avoid it, need to avoid it, hide from it. So we might see these different symptoms that can fall in a bunch of different categories, but if we're not looking at it through the lens of gender dysphoria, if we're not understanding this piece, we're missing important information. So really trying to understand how this might be playing out in your clients, not just sort of guessing, but absolutely asking and trying to sort of inquire about how is this affecting you? How does your gender dysphoria affect you here? Can you tell me more about this? Really sort of eliciting what we need to know so that we can really support our full client, regardless of what their sort of primary presentation is, whether they're coming in for depression and this is something, or they're coming in for gender dysphoria, thinking about how does your gender dysphoria affect these other aspects of life? Next slide, please. So this slide, I can't underscore enough. It says waiting to treat gender dysphoria until other mental illness symptoms are treated can be harmful because gender dysphoria is often the root cause of other symptoms, right? And the reason we have this slide is because historically, sort of in the olden days, there was the idea that we can't treat gender dysphoria or even take a trans person seriously unless all of their mental health conditions are abated and they are the picture of perfect mental health, which of course makes no sense. And it makes, for any of us, right? Who is the picture of perfect mental health ever? No one, right? And it's particularly important because the idea is we absolutely know that treating gender dysphoria helps alleviate these symptoms. So it's sort of asking some, it's an impossibility, right? We can't sort of address, and I've seen this in a couple, a lot of times we'll see this with parents, parents of young children and parents of adult children because a lot of times adult children are still sort of relying on their parents for healthcare coverage, financing, support in lots of different ways. And so they're looking and parents will say, well, just get through college and then we can deal with this whole gender dysphoria thing. It's like, oh, really hard to get through college and all the stress when I'm not, like I'm literally at my worst, not my best. It's this idea of when we address gender dysphoria, and I'll talk about what it means to address gender dysphoria in my next slide, but when we do that, only then can we expect our clients to have sort of the opportunity to be at optimal functioning, to be able to sort of then go, okay, now I can really get a handle on this depression. Now I'm gonna start addressing this anxiety. Now I can sort of prioritize college. But this sort of, when we really think about sort of Maslow's hierarchy of needs, gender dysphoria is critical addressing this. This is sort of like the core of almost like base level what I need to do first. And this is so important because I don't think we're taught this way. This hasn't been the way that we've either taught or seen it done or heard about it being done. So it's in some ways what we're asking is as a paradigm shift to really understand that treating gender dysphoria is almost one of the first things we really need to do. And treating sounds really sort of intense. And so I would, I'll ask you to go to the next slide, please. And I'll get into what we mean by that. What we really mean by treating gender dysphoria is really gender affirmation, beginning to affirm someone's gender identity, affirm who they are in all the various ways that we can do. And some of that's sort of up to the medical doctors and clinicians. A lot of it's not. A lot of it is using the correct pronouns, whatever those are for somebody, allowing people to express themselves freely, fluidly, comfortably as a society, as parents, as practitioners, as friends and family. And the idea is, and then of course, yes, that spills over to clinically or therapeutically. What does that mean? That means absolutely creating a gender affirming experience where we sort of explore and certainly don't pathologize, but affirm the experience of gender that is sort of outside the binary that does not align with birth sex. These different ways of experiencing gender and the different needs that folks have to feel really like their authenticity is both evident internally and externally. And those align and those feel really comfortable. And so this is sort of clinically what we know is really effective. And the trans community has known this forever. And luckily there's mounting research that is beginning to indeed demonstrate to the world that gender affirming experiences and gender affirming interventions, including medical interventions, reduce gender dysphoria and they improve overall wellbeing, you know, reducing psychological distress, improving mental health outcomes, all kinds of things. And so this is sort of what we mean by addressing gender dysphoria is beginning to help people be affirmed. And when you're affirmed, your gender dysphoria goes down and your overarching wellbeing goes up. Next slide, please. This is a really nice slide that I like because it begins to talk about what it feels like to be affirmed and the way that trans folks are talking about, and thank goodness, increasingly researchers and practitioners, which is this idea of not only are we looking for folks to sort of be affirmed and feel okay, but actually you can feel really sort of euphoric or really confident and comfortable in your gender. And this is a participant who's sharing her experience that when she gets correctly gendered by strangers how that gives her a sense of joy and excitement and gender euphoria. And we've recently began to do a little bit of a deep dive into the impact that affirmation has on experiences of euphoria and what it means to feel euphoric for a trans person around their gender can be things like feeling just right, feeling confident, feeling really comfortable, all those just sort of good feelings all the way to sort of feeling like they're sort of walking on the clouds or can we walk on clouds, whatever that is, floating on the clouds, that kind of thing. And so it's really, really important. And this is an example of someone who sort of since she started hormones, right? This idea of being affirmed medically allowed her to feel right and to be perceived in the way she needed to, to walk through the world as she is and be recognized and treated that way. And it's really important. Next slide, please. And so this last slide of mine, and then I'm gonna turn it over to our colleagues who colleague who was going to share his own lived experience. But this last slide is really important because what it talks about is this idea that as folks, trans folks realize how to have more access to understanding who they are and more opportunity to access gender affirming interventions, hormones, surgical interventions, laser hair removal, lactose, things that sort of affirm them, the more they are going to seek out providers. So psychiatrists, psychologists, I'm a social worker, different people in mental health providers who have expertise in this area to get their letters. These letters are often called gender letters and common practice. But unfortunately, in order to access gender affirming services, there are still hoops that have to be jumped through. And one of those is receiving a letter from a therapist, indeed confirming that someone is who they know themselves to be. So confirming that they are indeed trans and that they do have a gender dysphoria diagnosis. And because this is a wonderful opportunity and people are able to seek gender affirming care, they often will be coming through our doors more often or our colleagues' doors. And so the idea that folks are gonna maybe be seeing providers more is really important for a couple reasons. One is we may, in this assessment of gender and co-occurring issues, we may uncover some mental health concerns that need treatment. So we may be seeing clients for a range of things that we wanna be able to sort of delicately understand the difference between gender dysphoria and depression and anxiety and the way in which they interact and co-occur. We also wanna make sure that this experience is incredibly safe and affirming for the clients who step through our door. This might be the very first time they've been seeking out mental health care services, psychiatric services, therapy services. This might be their first interaction. We need to be positive. We need it to be affirming. We need it to be different than it has been in the past. And so I sort of expect that all of you that are here are here because you sort of believe that and sort of are drinking the same Kool-Aid as I am that you sort of, we want to really have the best available services for our trans clients who are seeking care. And we know that hasn't been the case. So we sort of wanna see these opportunities when folks are coming through the door for the first time as wonderful opportunities to start and create really safe therapeutic experiences where we're engaging clients from step one till the very end in a really affirming, really competent and really informed way around all aspects of themselves, right? From their gender dysphoria to their gender euphoria and all the other needs in between. So that's sort of where I'm gonna end my piece and turn it over to Dr. S who's gonna share his own personal experiences that will really bring this talk to life. So thanks. Thank you. I'm Dr. S and I'm going to share my previous experience from when I was closeted, came out and then transitioned. So I had been closeted since childhood about my gender. I was self-conscious and sensitive for as long as I could remember. The only reason why I did not come out much sooner in life was because I thought it would be hurtful for the people I was close to. I experienced a lot of anxiety about this, which I never talked about. And at last sought help for anxiety during grad school. Prior to this, friends and family suggested there was nothing wrong other than that I was just sensitive. In the first appointment with the psychiatrist, there was a questionnaire and I was so relieved that my psychiatrist acknowledged that I had anxiety. Just as I said, I did. I felt validated. I was no longer just sensitive. Yet I kept my gender to myself, the reason why I was so anxious. Following an adverse reaction to a psychiatric medication for anxiety, I was diagnosed with a mood disorder. Due to adverse reactions to mood disorder medications, I was diagnosed with a severe mood disorder. My friends and family had no idea what was happening to me. I could not hold the secret about my gender in any longer. I came out to my psychiatrist. I came out to my psychiatrist. His first reaction was to say, I don't want to be involved. It was devastating for me. It was completely different from the first appointment when he acknowledged my anxiety. He was the first person to view me as not as sensitive. Why was it suddenly so different? It was the core of who I was and the shock was beyond what I can express. He prescribed a higher dose of a medication to help with my resulting deep sadness, which I had conveyed as a feeling of depression. The medication turned out to be at a toxic level for me, leading to hallucinations. Friends and family were very supportive of me. And during the following two years, I transitioned. I had seven surgeries and a new name. I felt refreshed and it was wonderful. Over the course of my therapeutic treatment with this psychiatrist, I had been prescribed 11 medications, five being the most at any given time. But after 18 months of starting my transition, I was no longer taking any of the mood disorder or anxiety medications that I had been prescribed previously. My psychiatrist never really fully acknowledged how various comments that he would make over time to discourage me from transitioning felt rather hurtful. It was very hard on me because he was the first person to listen to me when I said I wasn't as sensitive. I had cherished and still do cherish that initial acknowledgement. I started seeing a new affirming psychiatrist much later on after I transitioned. It felt refreshing again to feel heard and seen once more. My whole self feels valid and it is such a relief. I'd once hid parts of myself from my old psychiatrist because it felt so hurtful and shameful to talk about my whole self. Now I can feel like an entire person again. I wanted to start by saying, thank you very much, Dr. S. I wanted to start by saying, thank you very much, Dr. S. That was really powerful and really sad for me to listen to because I'm sorry for your pain. And I know that it's a really all too common experience. I'm grateful that you found someone else. I think your story is, I sort of thank you for your bravery in sharing that story because I think it's so beautifully told and so important for other people to hear, particularly folks on this call about the important role that we have when someone is trusting us to be able to hold their whole self and to value their whole self. And I think it's so very important. And it's interesting because just for all of you all listening, it's really interesting to me because the three of us put up this presentation together separately. And in hearing Dr. S's life story and his experiences, it's just so telling, right? Because we didn't put it together after we heard his experiences. This is the experience of so many. His personal experience is reflective of way too many folks. And so I commend him for his sort of bravery and courage and sort of sharing a personal story with the world in order to improve care for everyone. And I really am deeply saddened by what I know that this stuff, this still goes on, right? It's still happening. I'm heartened by the fact that you're all here today and hopefully thinking and learning and listening and have a lot to add. So I just wanted to say to sort of share my gratitude with Dr. S and share my gratitude with those of you who are here and trying to learn and trying to be a more affirming therapist or psychiatrist or individual. So thanks. Well, and I would just like to add to that is that I think a number of really interesting things were said in the presentation also about our expectations regarding our clients and our patients. And one of the notable things I think you said was, particularly we don't ask individuals with gender dysphoria, go home and resolve this and come back or resolve your other mental health problems and we'll come back. There's a universal design, so to speak, in integrated care. We don't ask an individual who experiences schizophrenia and substance use to go home and get sober and then come back and we'll take care of their schizophrenia. We don't ask a person with any type of medical disorder like diabetes to go get their schizophrenia under control and then we'll help them with their metabolic problem. So I think what you said is really genuine about is that an expectation? And I think that's something as practitioners, we should remind ourselves that the integration and the simultaneous nature of life requires us to address these issues, particularly among individuals overall with recovery of mental health, but maybe especially in our expectations and how we relate to our clients who have trans or non-binary identities. All right. Thank you so much for such an interesting presentation, Dr. Rosano, Dr. Austin and Dr. S. Before we shift into the Q&A, I do wanna take a moment and let you know that SMI Advisor is accessible from your mobile device. Use the SMI Advisor app to access resources, education and upcoming events, complete mental health rating scales and even submit questions directly to our team of SMI experts. Download the app now at smiadvisor.org slash app. Okay, so we have a couple of questions. Please feel free to add more as we begin this portion if you do have some. So one question that we have is, what are some recommendations for how I as a, somebody who identifies as a cisgender person could provide inclusive services to somebody who is experiencing gender identity issues? I'll start with that. I think, I'm not, I'll talk about sort of the broad down to the narrow, but a lot of times what we wanna do is as we are thinking about how do we create a practice that's sort of trans-inclusive, we wanna think about the kinds of, what does our intake look like? Do we have space on our intake that acknowledges identities that are just not man and woman, that includes sort of non-binary and other gender identities that are just not cisgender? That includes sort of non-binary and other sort of gender identities in our intake forms. When we're thinking about sort of making sure if we have a physical space or some space where we're sort of recognizing, they come in that there's a trans flag or trans colors, or we have magazines that are inclusive of trans and queer people, as well as cis and straight people or families. So those are some of the sort of ways in which we can sort of create that space from the beginning. We can certainly, if we're doing Zoom, have our pronouns on there like we all do today. And as you're doing this work, sort of, I would say it's really important as you are then opening the door and saying, I'm treating or you're marking on your little psychology today thing, I treat trans and non-binary clients, that you do the corresponding work to say, I have the competence necessary. And so sort of learning, learning. So attending this webinar is a beautiful start and reading as much as you can, looking for other webinars on trans and non-binary identities. The Center of Excellence, the center that I'm a part of, has a ton of resources from the early days up. I think you all said that you also are doing the whole series on trans and non-binary and LGBTQ folks. So really taking advantage of these resources is so important so that once they come in the door, you actually have the skills and competence to begin to support them is really important. Thank you. Does any of the other presenters want to add how we can provide gender affirming treatment? Well, I would say I shouldn't, I'll paraphrase Alice Walker, you know, when she said feminism is one of the great humanisms. I think of this not necessarily from an exclusively feminist perspective, but from a humanist perspective. Many of us as mental health providers work with individuals where we can't exactly describe their experiences, but we share humanity about those experiences, about feeling like an outsider, about feeling like you don't fit, about feeling anxiety, depression, whatever it is. And so I think just having that openness that all of us would have, you know, I think the distressing thing to hear again, came from Dr. S who experienced a psychiatrist who was open and to that maybe emotional humanity or the shared, I can help you with anxiety, I can help you with depression. But when the source of that anxiety made that practitioner uncomfortable, they shut down. And I think that's the place where, whether we're cis or heterosexual or not, or whatever things we all are, we share that common humanity and that's where we should approach people. And I think people feel that when you can engender that to them, great word to use, but when you can use that with them, they feel that. And I think the openness will allow you to have a much more productive clinical and recovery oriented relationship. Yeah, I think Dr. S's story was a great example of how not to respond. And so I think that those are some good ideas for how we can respond, what you just gave. So there are a few questions around children and, you know, kind of working and navigating that with parents. So I'll ask this in a few ways. First, are there good resources for parents and for children in like any resources you can share about them to access information when their child is maybe experiencing some gender dysphoria? So I'll start with that question and then I'll follow it up with another one. So there's some great books. There's an amazing book by Diane Aronsaft called The Gender Creative Child that is on Amazon. I just think that book is, Diane Aronsaft's amazing. She's a psychologist. She does gender work for decades. That's a beautiful book to start with. There are some really excellent, so I'm gonna say again, the Center of Excellence has a really good, a lot of, has been doing a lot of work recently on trans youth resources because of the backlash in this country around supporting affirmative care for trans youth. But also there are other websites that are, Gender Spectrum is a great one that's been devoted to trans and non-binary kids for a really long time for parent supports. And so I think there are actually a lot of good resources out there. I think, I would say that those, that book is amazing. And then there are a lot of really, really good websites with support groups and links and all kinds of things. So that would be a great starting place, yes. Yeah, and so from that, do you have recommendations on how to navigate a situation where a parent is not affirming? And I know that's not an ideal situation, but is there, how would you recommend navigating that? Yeah, I would say, I mean, honestly, in almost every single situation, okay, so in our center, and Angela, Dr. Weeks can speak to this with me. But we think about affirmation as a spectrum. So if parents are like not usually not affirming or they're affirming, they're somewhere in between. They're trying to figure this all out. It's really new to them. I have rarely met someone out the gate who's just like, this is amazing. I know exactly what to do. And so I would say every parent needs support. A lot of them come in either very against it or very scared or very hopeful that this isn't it. So a lot of the work that we do is really around supporting parents and helping them understand that having a child who's trans or non-binary is not a bad thing. It doesn't need to be disappointing. It doesn't need to be, it's not a negative, but there's a lot of, it's a paradigm shift. It's a lot of education around that. So again, we really work with them. So one of the things I think you said in the intro is the work that we do. We have an intervention, my colleague, Dr. Craig and I have an intervention. It's called Affirm Caregiver. And what it is is it's a seven session intervention aimed at helping parents, caregivers, whether it's mom and dad or foster parents or grandma, learn to become more affirming. We recognize that usually parents were not taught how to parent in this way. This was not something on their radar. And we also know that it's literally the most important thing for young people's wellbeing is to have their parents support and affirmation. So we usually help guide them through this, whether it's through our intervention or through this idea of helping parents understand the importance through a range of things, right? Psychoeducation around why does it matter if I affirm my kid or not? Why does, and sort of in the same way that Dr. S mentioned, when he was able to be affirmed medically and socially, all of his other mental health concerns debated. When he was able to live as his authentic self and be validated and treated and acknowledged and seen in that way, a lot of his concerns issued. Most parents really deeply want that for their child. It's just very scary. So I would say it is much more rare to find a parent who's like gung ho and ready to go than it is to find a parent who's really struggling. And so I would expect that most of us are gonna run into that and be prepared to meet the parent where they're at and help them recognize they need to catch up to their child in order to support them. So there's a couple of questions about gender and sex as they relate to each other. So one person explained that they have a person who identifies as transgender who does not believe that the gender and sex are mutually exclusive. Is there any recommendations on how to talk about that with them? Then I'll follow it up with a question else related. I don't know that, I'm sorry, I don't think I understand the question. So the transgender patient considers sex and gender as the same. And what we teach and when we teach terms, right? We teach transgender, we know there's separate gender and sex are separate. So is there any guidance on how to approach this with some of them? I guess I would say, you know, I don't expect my clients to always use the same terms or to speak in the way I do as an academic or think in the way I do as an academic or a researcher. So I would say it's only matters if in some way it's important to them clinically, if in some way it's getting in the way of their feelings of confidence or if it's somehow creating shame. And if so, you know, the gender bred person or the unicorn, one of these different things could be useful tools to talk about that and explore, even if a client doesn't wanna use the same language as us, often they don't and that's, I mean, I think they are entitled to use the language that fits best for them and even the constructs. So I would say it's only important to do that if it feels like it's getting in the way of the client's wellbeing and then sort of just talking through the different tools and just trying to understand maybe what things mean to the client and how that view is serving them. You know, I would add to that, you know, as all of us are continued scholars of the individuals we see as clients or research participants, service recipients, in our case, Shereen, you know, I think what's important is I don't think we all know the answer to that question. You know, neurologically, imaging studies are just starting to demonstrate that gender is not, you know, this lateralized thing in the brain that we might've thought it was and that gender is actually, from a cellular level, dispersed throughout the brain. And, you know, as we continue to involve in neuroscience, we're gonna, I think, evolve in people's experience. But I have to agree with Dr. Austin that when you meet patients or clients where they are, if that's an issue for them, then you're going to have to address it. But if it's not, you know, I think you move on. But I do think it's healthy for us as practitioners to sometimes say we don't know. Do, you know, is there a linear cause that a child might experience gender differently? I say no, I don't think you can say that right now. And so, you know, I think that also helps parents take the pressure off. The only other thing I'll say developmentally is, you know, parents tend to have scripts just like everybody else and anticipatory ideas about what will happen with their children. And so sometimes, you know, giving them a little space to say this is not what I expected is fair. And see that perspective from parents. Not, you know, not that parents are always going to choose the right language. But most of them are gonna try, I think. And so to give parents a little room to say, boy, this is not what I expected, help me relate to my child, help me relate to my feelings, whatever things. And I think it's, you know, a very fluid relationship. I'm gonna go back to kind of, because what you just said brought me back to another question that I'm reading. So thinking about, you know, at what age should we start introducing the idea of gender, gender dysphoria, gender affirmation? Is there any recommendations around when that should be introduced? Is it like school age or, you know, what age do you think would be good? I mean, I think, so this is like a complex question, but I think, you know, I think kids are already introduced to the concept of gender, they're into it early. In terms of gender affirmation or transness, I mean, I think, you know, there are books for children. I mean, Jazz Jennings wrote books for children. These are appropriate conversations. There's beautiful books in the library that talk about sort of gender and fluidity. And certainly a lot of the things that Dr. Rosano was talking about earlier, things that happened early on. So I think there's been a strange thing that's happened where people have decided transness is somehow not appropriate discussion and seen as sort of an adult conversation, but it's certainly not. It's sort of in the same way that all of these other things are talked about, you know, sort of creating the conversations differently. I think they've been talked about, right? You think about little kids are told that's a boy toy and that's a girl toy. That's introducing the conversation in preschool and before. There's other ways, so it's getting introduced, maybe not in the ways we all would want. And so there's other opportunities to have other different conversations and introduce a sort of more diverse view or more inclusive view of gender and gendered experiences and roles and attitudes. And I think maybe Dr. Rosano can add to that based on sort of her earlier slides. Well, and I would agree with that. And my argument, not to sound cynical, is gender, in some cases, introduced to an individual before they're even born. And you've made a decision about everything, you know. Piaget would argue that infants don't know blue is a color, let alone that it's for a particular group of people. You know, the other thing that I think is really important is when do we not only, you know, we introduced this from the child's viewpoint of a child comes to us with a view about gender or an experience of gender. When do we hear a person say to potentially an anatomically identified boy child, boys don't cry? Because for me, that goes beyond selection of an object. It's not a toy for you. Okay, fine, I'll play with something else. How do I process my emotion that I'm crying? Was I afraid? Was I whatever I was as a small child, I'm now being told that's not an emotional experience for me. And so we start shaping people with regard to gender rules very early and whether they're, you know, experiencing them from us saying I want a toy or I want to do a thing, we're also telling them, you know, both on the boy's side and the girl's side, frankly, what things are for them. And sometimes that's, we should maybe as a, you know, think about that, you know, I guess in the time we have, why is it inappropriate for a young boy to cry when he's afraid or they're afraid, however they identify why we modulate that emotion, particularly in that segment of the population. Yeah, I agree. And I think, you know, the idea that, you know, sort of like the idea of sometimes we should, right, the question is, when do we introduce it? It's also like, how can we stop introducing it, right? Why are there a boy line and a girl line? Because as we think about kids who are, kids and adults and teens who are non-binary or age under, there we sort of are giving them zero space to be. And so these are this idea of how do we create spaces that are really uncomfortable and safe for everybody to navigate their own identities and to be able to speak up about it, right, without shame and know that they're gonna be received by psychiatrists and therapists and parents in a way that's welcoming of their whole identity, whatever that is around gender identity, gender roles, emotional experiences, and that's sort of, that's where we really should be focusing. And unfortunately we get caught up in some of these other things instead. Well, thank you so much for your questions and for your responses and for the really important information that you provided. There are a lot of resources listed in the webinar as well. So if you download the PDF, you'll be able to see more resources there. And there were some put in the chat as well, including to the Affirm Therapy, a treatment evidence-based practice and also the language guide that I mentioned in the beginning. So there were more questions that we couldn't get to. And so if there are any topics covered in this webinar that you want to discuss with colleagues in the mental health field, you can post a comment or question on SMA Advisors webinar round table topics discussion board. This is an easy way to network and share ideas with other clinicians who participate in the webinar. And if we didn't get to your question today, if you would like to submit, or if you have any other questions that come up related to this webinar or any other evidence-based care for people with SMI, you can get an answer within one business day from one of our SMI Advisor National Experts. So this service is available to all mental health clinicians, peer support specialists, administrators, and anyone else in the mental health field who works with individuals who have SMI. It's free and confidential. So SMI Advisor is just one of many SAMHSA initiatives that are designed to help clinicians implement evidence-based care. We'd encourage you to explore the resources available on the Mental Health Addiction and Prevention TTCs, as well as the National Center of Excellence for Eating Disorders and the Suicide Prevention Resource Center. These initiatives cover a broad range of topics from school-based mental health through the opioid epidemic. To claim credit for participating in today's webinar, you'll need to have met the requisite attendance threshold for your profession. Verification of attendance may take up to five minutes, and you'll then be able to select Next to advance and complete the program evaluation before claiming your credit. And please join us on August 26th as Dr. Lori Rainey presents Telementoring and Education for Treating SMI in Rural Settings. Again, this free webinar will be August 26 from 12 to 1 p.m. Eastern time. That's a Friday, next Friday. So thank you for joining us. Until next time, take care, and thank you again to our presenters and for sharing your stories.

webinar

Transgender

Non-Binary Clients

Serious Mental Illness

gender dysphoria

inclusive services

gender identity

knowledgeable clinicians

supportive environment

supportive mental health care