Hello and welcome. I'm Shireen Khan, Senior Director of Workforce and Organizational Development at Thresholds, Illinois' oldest and largest provider of community mental health services and social work expert for SMI Advisor. I am pleased that you're joining us for today's SMI Advisor webinar, Inclusive Evidence-Based Practices in Gender Non-Binary Mental Health Services. 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. Today's webinar has been designated for one AMA PRA Category 1 Credit for Physicians, one Continuing Education Credit for Psychologists, one Social Work Continuing Education Credit, and one Nursing Continuing Professional Development Contact Hour. Tickets for participating in today's webinar will be available until October 30, 2021. Slides from the presentation today are available in the handouts area, which is found in the lower portion of your control panel. You can select the link there to download the PDF. And 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 have reserved 10 to 15 minutes at the end of the presentation for Q&A. Now I would like to introduce you to the faculty for today's webinar, Drs. Lisa Rosano and Brendan Hill. Dr. Lisa Rosano is Associate Professor in the Department of Psychiatry at the University of Illinois at Chicago, serving as Deputy Director for the Department's Center on Mental Health Services Research and Policy, and as Director of Graduate Studies at the UIC College of Medicine. For nearly 30 years, she has conducted research, evaluation, and education programs dedicated to improving the health, wellness, and community participation of people with mental health conditions. Dr. Brandon Hill is the Executive Director of the Howard Brown Health Center for Education Research and Advocacy, as well as a research fellow at the Kinsey Institute at Indiana University. Dr. Hill's research focuses on structural and system-level interventions that address barriers to sexual and reproductive health care, with a particular focus on the health and well-being of LGBTQ plus use of color. In 2020, Dr. Hill was named one of 50 Distinguished Sexual and Gender Health Revolutionaries by the University of Minnesota Medical School Institute for Sexual Health and Gender Health. Thank you both for leading today's webinar on this important topic. I'll now hand it over to Dr. Rosano. Thank you so much for Shireen, and welcome everybody this afternoon to this presentation. My name is Dr. Lisa Rosano, and in addition to my faculty appointment at UIC, I also serve as Vice President for Research at Thresholds, as Shireen noted, one of the largest mental health providers in the Midwest with a long history of diverse types of mental health services and programs. I'm very excited about this presentation, and I'm very excited to share it with my colleague, Dr. Hill from Howard Brown. I identify as a cisgender woman and as lesbian, so I thought I would say that here at the top of the hour. Neither Brandon nor myself have any disclosures that we have to present. I will say that some of the things that I've talked about today, and included in this development of this presentation, was supporting medical student research in the area of gender non-binary services in mental health, and it was supported by two federal grants from the Administration for Community Living. The summary of today's presentation really focuses on an intermediate level session to identify the implementation of evidence-based practices in mental health services for individuals who identify with diverse, non-binary, transgender, or other gender-fluid identities. We will include in the session case presentations and describe treatment planning for clients in this vulnerable population, including considerations related to implementing services and models that are culturally mindful and that continue to promote community engagement. Information is also going to highlight coordinated care related to the social determinants of physical and mental health, including the impact of stigma, poverty, healthcare access, and exposure to trauma. The learning objectives for today's presentation focus on completing this activity participants will be able to review contemporary terms and concepts associated with trans and gender non-binary individuals and communities, evaluate key clinical practices and approaches that address the needs among trans and gender non-binary individuals, incorporate strategies that select, implement, and evaluate person-first service interventions within clinical programs, and working with non-binary populations and their support systems, and certainly to discuss the challenges among members of the healthcare treatment team to promote and sustain culturally mindful training. So the place where I thought I would start today is a discussion of some of the terms that we use in identifying gender and sexual orientation. What's important about these terms is people use them a little interchangeably, and in this day and age, it's really important that we understand and we communicate with one another in ways that we all understand and mean the same things. So historically, when we've talked about sex, we're really talking about the thing that's assigned at birth or perhaps during an ultrasound, and it's typically based on the appearance of external genitalia. Now you can look at genetic typing and find that genetically people identify as XY for males and XX for women or for girls, but typically when you do an ultrasound and you assign sex, it is based on that external genitalia. Now what's important about this is that from this idea of assignment of sex or the presentation of sex at birth, we're going to move to constructs of gender, which then move from biological or organic types of ideas to ideas about appearance and personality and certainly attributions that we make about individuals based on whether they are a boy, man, or of the masculine, if you will, or being a girl or female or of the feminine. What's really important is that gender roles and gender concepts are very culture bound and our sense of masculinity and femininity in one country or here, say in the United States, it may have some parallels and may have some overlap to concepts in other countries, but other places may also extend either to more liberal or fluid as well as to perhaps more conservative views of gender or what would be considered of the masculine or of the feminine. There's also cultural differences in the attributions that we make about individuals who might step out of those roles or those identities that are associated with their sex. And so in some situations, there is more flexibility for people to, you know, experience both sides of gender versus being primarily have the expectations that they will say on one side of it. The important thing here is that whether it is our social behaviors of gender role, whether it is our more cognitive structures of gender identity of how we conceptualize our maleness or femaleness or our gender presentation, we start from a fairly dimorphic construct because we start really from the concept of sex. And so if we're male or female, we then have a category of behaviors in our gender role and how we identify with the maleness and the female. And from that, it has been principally a dimorphic conversation of gender. Sexual orientation is different. Sexual orientation is the romantic and perhaps intimate relationships that individuals have. Are they interested and attracted to people who are the same sex or the other sex? You can see here we have a number of terms that have evolved in terms of sexual orientation. The important thing to consider is that people's sexual orientation and who they choose or have emotional or intimate attractions to or sexual relationships with is not gender bound. And in fact, the opportunities for people to express themselves in a sexual manner are often very separate and unique compared to how they might identify with their gender identity. What's important about this is that people make often attributions about individuals in the non-binary or the transgender community based on how they identify with their gender. And those things might not necessarily align with sexual orientation. And so it's always critical to consider those two things very separately. So what do we actually reveal here with gender? And as I said, sex creates this foundation. And so our gender framework comes for that. And what's important about the gender reveal, and I'll say upfront, I don't have any issues with a nice party. I like a nice party and I actually like a nice cake once in a while. But I think what's interesting about the gender reveal party is that we have taken a social construct and we have looked at medical technology that allows us to identify, again, with external genitalia, what our infant is going to be. And we can plan around what that infant is going to be. What I think is interesting is that based on that sex, we decide to create these scripts and we have written a script and we've identified behaviors and we've made attributions and we've constructed a whole social role for a person who hasn't even been born yet. And what's interesting about that is most people think, you know, is the gender reveal party really for the infant? And I would contend no. I would say developmentally, most infants from birth to at least maybe six or eight months old probably aren't going to have a lot of divergent or dimorphic needs in terms of their sex or gender. Maybe their sex, depending on what kind of diaper you're using. But all in all, infants do not have a sense of gender. They don't have the cognitive space to understand their maleness or femaleness yet. So we, as a society, already are making attributions about who they want to be. What's really important about that is that as they grow up and they experience themselves, they develop their own identities, their own sexual needs, emotional attachments. They conceptualize not only their gender identity, but perhaps even their cultural identity, maybe even a religious identity, depending on any of the factors that influence their life. What's important, though, is that by assigning these roles and by assigning the attributions that we make about people who cross over and step out of the gender role, we don't give people the opportunity to really define themselves the way that they probably would or the way that they can in a very open and experiential kind of way. We've moved now from terms of just gender and transgender to these three very important ways that people describe themselves. So at the top of the presentation, I described myself as a cisgender woman. By doing that, I'm identifying that as cisgender, my gender identity and my femaleness is to some degree aligned with the sex that was assigned to me as birth, as a woman. For an individual who's transgender, in many cases, these are individuals who have been born or identified as one sex, but in their presentation, their identity, in their cognitive space, in the way they want to present and behave in the world, they more align with the gender roles and attributes of the other sex. So transgender people often will be more likely to identify with more of a gender role that is other than assigned at birth. This brings us to gender non-binary and gender non-conforming individuals or NBs, as people may refer to themselves. An NB is a person who really doesn't want to pick a side. They don't necessarily only present or feel themselves either intellectually, emotionally or socially in a masculine space or the masculine. They don't necessarily feel themselves exclusively in those roles or identities in the feminine space. And so they want to move in a more open way between what are the types of behaviors and types of activities that they like and that they feel express them best, regardless of whether or not those things would align with the biological sex that they were assigned at birth. We also see some more modern terms like genderqueer or agender. People who are genderqueer typically will not align with a binary understanding and then many times people who are genderqueer may say that they feel more in the masculine space or the more feminine space, but that's a more transient and more, again, fluid type of conversation. Genderqueer people might think of themselves as both. They might think of themselves as having attributes of each of the genders. You can see here the Greek term androgyny, which I think is important because the concept of androgyny is older now, but in the 1970s, the idea that people could in fact work between the genders and while they might identify as male or female, they could also participate in activities that while typically reserved for the other gender, were not exclusive to them. The idea of that crossover or the idea of having both masculine and feminine and a mix of characteristics depending on how you identify them was research that came out of psychology and Sandra Bem. Even in her own research of androgyny and these kinds of concepts, Bem in her later research moved to a much more gender fluid idea that we did not have to have a dimorphic gender and that people could move very freely between both of the gender roles in how they present their own identities and their own gender roles. That does bring us to this concept of gender fluidity, which I think I've said here already. Many people whose gender identity will not match to what was assigned them at birth, but it also does not mean that they are going to stay in a singular gender space. They may not identify as cisgender or transgender or even enby. They may just say that they have gender fluidity and they express themselves somewhere in there at different places throughout their life and throughout their different roles. They don't really feel that they're ever on a particular side because their gender and their self-expression is constantly evolving and constantly moving. In mental health, we can certainly see that the idea of gender fluidity is not new and that really there are some indications from research that we've done that gender identity is not necessarily related to psychiatric illness. What's really important about that is that conceptually any kind of gender difference or cross-gender identity typically and historically has been pretty psychopathological. For us as behavioral health clinicians, we might have to approach our patients and clients very differently about how they express themselves, maybe asking them and not assuming what is their gender identity based on their sexual orientation. Do they identify as cis or trans or even enby in our early conversations with people? Asking people to identify themselves, asking people the preferred ways that they would like to be called, asking people their pronouns is a way to really respect this and to have a conversation where the person is able to really identify what they are and talk about their gender openly and transparently without in some way it becoming pathological. The other thing that's important is that some people, depending on their thoughts or the experience of their symptoms, they might not be able to consider themselves as non-binary or feel safe in a space that's non-binary. This might be a way for you to talk to some individuals about gender fluidity and the fact that they don't have to assign or particularly identify with one or the other. That comfort of knowing that gender fluidity is their choice and it's very common and it's very open can sometimes be something that really helps a lot of people find their way in this way. Importantly is that we're moving away from these ideas as practices in the psychopathology. So as we move toward evidence-based practices, here are the things that we typically will want to talk about in terms of what are treatments and what are the foundational things that the services and practices that we would consider evidence-based would all have in common. I'm going to speak a little bit about foundational knowledge and awareness as I have and then Dr. Hill is going to move on and talk about stigma, some lifespan approaches and some of the work that they do at not only Howard Brown, but throughout his career in this area. So we know that these broader concepts of gender are important. We know it behaviorally. We even know it neuroscience. We are looking now at ways that people can map gender scripts in the brain. There are sections in the brain. Early on in neuroscience, people used to think of the very sexually dimorphic brain where women were on one side and men were on the other side and the truth is most of the research in neuroscience is demonstrating that in our brains concepts of gender or areas of activity related to thoughts about gender, thinking about gender roles, talking about gender identity are actually distributed throughout the brain. And so these are things that really are very integrated and we're learning more and more about. And so this idea of the sexually dimorphic brain is also something that we're moving away from. We've also tried to talk more in health and medicine about what we do with individuals who typically would be considered intersex. Now in many cases, the parents are given a choice to medically assign more of one genitalia to the other. And what research has really shown there is in many cases, that is not necessarily the best approach while something has to be done obviously in infancy. Many individuals who have an intersex presentation, who have an assignment of birth or excuse me, assignment of sex or gender often as they grow up are not necessarily aligned with that gender and still something at least in terms of brain development, physical development and mental health and experience that is not necessarily something that is as fully understood as it could be. We also have to acknowledge that in psychiatry and mental health practice particularly, gender has had a rocky history in the DSM. And I say that with a little reticence because foundationally the purpose of the DSM is classification. And I think that that idea of the DSM as classification starts to get a little murky sometimes. What I think is very important to consider is that the first DSM really didn't have anything about gender identity in them whatsoever. They were focused on psychopathology, on abnormal behavior, probably the experience of psychosis, and things that we would know now as the very, very early presentations of schizophrenia, let's say. You see the first published discussion of transsexualism in 1980, and you also see some discussion of that in the World Health Organization. What's very interesting about this is we see some mixing here of transsexualism and transvestism, and not a very well-defined or well-compartmentalized discussion of how individuals present. And that's something that I think we continue to see in the general public to some degree. We've seen it in mental health practitioners. We see it in healthcare, where a lot of people still don't really clearly understand what might be the distinction between the fetish of transvestism and the experience of gender identity dysphoria or disorder that we would see now as a much more modern conceptualization of transgender behavior. Finally, in 2013, with what we see in DSM-5, is gender identity disorder is done away with and replaced with gender dysphoria. And what's most important about that is the paradigm shift here is not just to how we approach individuals' identity of their gender, but how we as mental health professionals approach their experience of anxiety, depression, their mental health experience of living with those feelings or, say, wanting to transition. What's important about this is the move in DSM-5 has a couple real foundational things that we have to remember. One is that gender nonconformity in and of itself is not a mental disorder. And this is really important because cross-gender behavior for many years was considered abnormal psychopathology. Gender variance is not a form of psychopathology. In fact, the real foundation of DSM-5 and its move to gender dysphoria is the dysphoria itself The dysphoria itself is what is considered the mental health issue for most patients. The feelings of disturbance, the ego dystonia, anxiety, however the patient describes them, is really that they're not expressing their gender or they're not living the gender they feel the way that they should. And that the pathology is not being able to be an authentic gender-identified person or gender-behavioral person. It's really from living and trying to fit into a mold where the person really does not experience their life. They don't experience either maleness or femaleness or, again, fluidity in a way that they can be really fully expressive. DSM-5 also looks at it developmentally by giving children a classification for children because this is something that might be changing over time and might present differently developmentally in a person who is young, depending on their age, than what you might see in somebody who is an adult and has a much more maybe different or developmentally advanced, I say that with guard, but developmentally enriched sense of the abstractions of gender, what it means to present masculine or feminine in the world. Once individuals decide or elect to transition, DSM-5 also has moved on now to talk about individuals post-transition, which is important because after a person transitions, typically you would expect that the classification of gender dysphoria would not be present because they now hopefully would have reduced feelings of ego dystonia, fewer feelings of anxiety or dissatisfaction or any of the symptoms or feelings that they might report because the transition represents an opportunity for them to now live and express themselves in the gender or the gender role or express the gender identity that they feel most represents them. What's really important is how can we work within these systems to not only identify ways that people have transitioned and that have now felt a sense of recovery in their mental health, but it's also important to note that many people who transition are gonna continue to need medical care, whether it's treatment with hormones or they're gonna continue to have surgeries that might be related to how they wanna present themselves. Those are things that would be considered ongoing medical issues, but they would not necessarily be considered things in the line of a mental health disturbance or certainly a way that you would have some kind of mental health disorder. But I will say that like most individuals, there are no studies to say that an underlying psychiatric illness like schizophrenia or bipolar illness or any of the major serious mental illnesses are causal to gender dysphoria. In fact, at this stage, what most research would tell you is that the gender dysphoria in many cases would be the root of the mental health disturbance for some people. But we do still continue to see some things, I think that are remarkable and notable in terms of gender and people's presentation in the mental health system. And these things are probably less per se and not quite still fully understood in terms of research, but things like impulsivity, more suicidal ideation. One thing we do know is that individuals who are gender nonconforming, individuals who are transgender, people who seek transgender mental health and medical care are more likely to experience violence. They're more likely to experience things like misunderstanding. They might be called the wrong name. And so some of the things that people experience may not so much be a source of their gender transition, but the response that we continue to have in terms of a social world and how people do in terms of presenting themselves, the response they get from other people. Are they able to maintain their workspaces and things like this? While these effects are certainly notable and things that you continue to see at least in a therapeutic relationship with an individual, these would not meet the criteria for what we would have considered in the old standard of a personality disorder, but some of these personality effects are certainly important. We also do see some presentation of gender dysphoria and feelings of fluidity among more people who experience autism spectrum disorders and some people who experience schizophrenia. And particularly in the case of people who experience schizophrenia, they may feel very fluid because of the way that they envision or that they move between their own ideas of self and other. Now, neither of these things I mentioned because of a sense that more people with schizophrenia have gender dysphoria. They don't. Or more people or everyone with autism is going to have a gender dysphoria or ego dysphonia. They don't. But more and better psychiatric epidemiology is starting to look at the presentation of gender and the experience of gender among people who also have the experience of serious mental illness. What's important about that is that both gender and mental illness continue to have very cagey social presence. And while I think all of us here have interests in both of these topics, it's important to remember that stigma toward mental health and stigma toward mental illnesses and treatment continues to be something that we encounter in our world. Having said that, I will turn things over at this stage to the presentation to my colleague, Dr. Brandon Hill. Hello, thank you. Dr. Brandon Hill of Howard Brown. I use he, him pronouns. And I identify as cisgender male, queer person of color. I'm gonna pick back up with the other core components of evidence-informed practices and speak about more social ecological factors like stigma and institutional stigma. As many of you are probably familiar, stigma can be described as the institutional or individual stereotyping or specific marginalization of a particular group, generally and often on an arbitrary phenotype or trait, leading to limited access of social, economical and political power or resources. For transgender and non-binary individuals, anti-transgender stigma can be experienced both discreetly, but there's plenty of literature to support overt acts of stigma, often through harassment, victimization, violence, and even homicide, which is a higher frequency among TGNC individuals, which would be categorized as enacted stigma. There are, because of the way that society has historically excluded or marginalized TGNC individuals, there are already feelings of marginalization or the expectation of violence, which we describe as the perceived or anticipated stigma. And those two things contribute to the internalization or a negative self-concept that the individual might have, which then starts to impede on some of the mental health outcomes of a TGNC individual. When we look at institutional stigma, the next slide, sorry. Perfect. When we consider institutional stigma, so what is, how do we define institutional stigma? So institutional stigma can often be described by institutional affirmation. So for transgender and gender non-conforming, what is institutional affirmation? That's recognizing the existence of TGNB or TGNC individuals, their membership to a certain group, and social milestones. So it's critical that when we're looking at social transition and institutional stigma, we consider how those factors may actually influence mental health and wellbeing. Providers have to be aware that there are many external factors that may influence stress and mental health. In particular, if we look at institutional affirmation, an example can be identification documents, birth certificates, license, green cards, passports, social milestones that are very typical, diplomas that bear our name, merit certificates, documents that allow for leisure, like travel, hotel, airfare, employment documents, banking, taxes, healthcare insurance, and health records. These are all things that are pretty common in everyone's lived everyday life, but for a TGNC individual, may bring out disclosure of discordant identity with name, with gender marker, and actually can become a world of institutional stigma that will ultimately have stress and interact with mental health. And there's some growing evidence too, that on the physical side, that stress and discrimination in the American Heart Association just released this summer, a statement that with higher cardiovascular disease experienced among TGNC individuals due to distress and stigma. So we know that there is an internalizing of these institutional factors. Another component is that we want to recognize that there are ways to navigate through institutional barriers, and in particular, I'm sorry, go back. Okay, to move through, and that providers play a critical role in moving through an individual through gender-affirming care. Providers may be also asked to play a very clear role in social transition and institutional affirmation through providing letters, documentation, support, altering records within the electronic health records. And so we want to make sure that we're providing support, altering records within the electronic health record system to make the institutional affirmation an easier process for the client. Okay, so another approach to providing affirmative care to TGNC individuals is through using a lifespan approach. So when we're working with a client, particularly young people, we want to understand that their gender expression is very complex and that we have to match the developmental needs of the individual. So some TGNC individuals may come to the realization later after living a cisgender life. They may be older in age, they may have been married, have children, and they may come with particular needs of understanding where they are. It's not that they weren't TGNC, it's not that their relationships before this weren't valid, but it's important to consider the whole lifespan in which they've lived and how their experiences may influence their TGNC identity. On the other side, looking at considering young people, not all young people who may present with a TGNC identity will persist into adulthood. Both of these are to say that TGNC identity is not necessarily a phase, but because of the fluidity of gender that Dr. Rosano explained earlier, people may find their identity at different points in time. Much like our own, even for cisgender individuals, their gender expression and identity has probably not been the same throughout the entire life course, and that changes in fluidity are pretty common for both cisgender and trans and non-conforming individuals. It's important that we examine how the changes that might happen, depending on where people are in their lifespan, might change or start to affect romantic and sexual relationships. People might develop new feelings or new identities or orientations, and all of that fits within the experience of transgender non-binary individuals. They might have to also consider, if an individual's older, existing family formations and parenting, but with younger TGNC people, we might have to discuss fertility preservation or also what their long-term planning is for forming a family or parenting as well. So there's a lot of external things to consider, and the lifespan approach really helps us do that. The other is that there's a large wealth of knowledge from transgender and non-conforming elders who have lived through many different generations now, who have a lot to lend on the resiliencies that can be developed throughout the lifespan for transgender and non-conforming individuals. So one model that is often used is the Gender Affirmative Lifespan Approach, or GALA, and the GALA approach is a psychotherapy framework that's meant to really focus on the individualized client's needs and gender-related goals. As mentioned earlier, each individual may come to their gender identity with different outcome goals. These are not necessarily black and white, they're not necessarily binary or a two and only two. The GALA model's based on health disparity theories and research, and really focuses on therapeutic interventions that manage internalized oppression and trans negativity in order to improve mental health and overall well-being for gender-diverse clients. It promotes teaching about gender spectrum and fluidity as a natural expression of the diversity of gender, and allows clients the freedom to really find themselves within all of the possibilities of gender, rather than the narrow scope of a two and only two model. This is considered critical for trans-affirmative care and cultural competency, and is really pivotal for working with non-binary clients, for whom that the two and only two binary is not feasible and does not truly represent their gender expression. So what are the main components of the GALA model? The main goal, like I said, is to build resiliency among TGNC individuals, really develop gender literacy and knowledge about gender spectrum, to move folks beyond thinking in a binary and two and only two way, to promote positive sexuality and understanding of sexual feelings, emotions, connections, and to really facilitate and empower connections between medical interventions if needed, bearing in mind that not all, whether young people or adults, are necessarily needing hormonal or surgical interventions for their identity. So if that's desired, the model hopes that we will foster and empower connection between those. So the GALA model is also centered on these core tenants that it is transaffirmative care, that we recognize intersectionality or multiple positions that an individual may hold, whether it's race, whether it's economic, in addition to their gender identity, that it is transparent and honest, that the developmental differences in care across the lifespan, we recognize that there's a lot of movement and that we rely on interdisciplinary approaches. When it comes to interdisciplinary approaches, this is where we tie back in some of the sociological factors like stigma discrimination. We know that it will not be just, so that just holding a trans or non-binary identity does not situate people for more exposure necessarily alone, but the way that society marginalizes TG and B people will expose them to more violence, more harassment. And so we need other approaches to manage housing, employment, as well as discrimination, and those are often built in to these competent models. Okay, so we're going to shift a bit and we're going to look at assessment and therapy and interventions. So the first thing that we want to understand is what I kind of just recapped. So it's essential that we understand how mental health concerns may or may not be related to an individual's transgender or non-conforming or non-binary identity, and may also be related to the stress or the psychological effects or the environment that's surrounding them. This approach recognizes the benefits of considering the whole ecosystem in which the individual is actually living and striving to integrate and work with other resources that may actually alleviate some of the distress, but at the same time don't necessarily really directly relate to an individual's gender identity. When we do this, we know that transgender people are more likely to experience positive life outcomes because this provides an ecosystem of support and affirmation, and it tends to some of the most fundamental needs, like housing and shelter, employment, economics, affirmation through institution, not necessarily based on their mental health concerns or their identity alone. All right. So I'm going to present a case for everyone. So this is a kind of typical client, adolescent client. This is Ace. Ace is a 16-year-old who was assigned female at birth. Ace waivers between masculine and non-binary identity. Ace uses they, them, or their gender-neutral pronouns. They've presented for care because parents are concerned about their safety and report that they have attempted suicide over 15 times and have been hospitalized five times for self-harm or suicide. So a few things. Let's look at this case. They're young. They're under 18. They were assigned, so they'd be a minor. So they're assigned female at birth. They have a more fluid identity. They use neutral pronouns, and there's obviously frequent distress associated with self-harm and suicide. I should say this case comes from and is borrowed from a book, a handbook of many trans and non-binary case studies that's a great resource for providers and folks who work in social service. Lots and lots of examples. This is an abbreviated example. Okay. So Ace has recently dropped out of high school and spends time between their divorced parents' house, mostly watching TV. They consider their father more supportive as their mother comes from a religious family, and the family wants nothing to do with them because of their non-binary identity. Although Ace's father is supportive, he reports he doesn't understand his daughter, especially her tendencies to engage in self-harm and attempted suicide. So from that, you can already see there's limited social interaction. There's isolation. There's familial rejection. There's religiosity, and there's a mixed support because the father is still using inconsistent language even though they're the sole support for the individual. So what can be done here? So the main thing that can be done is to attend to the building coping skills such as mindfulness and stress tolerance to really manage the environment that's around the individual. They could use dialectic behavioral therapy. However, in this case study, the individual lives 100 miles away from the nearest trans group, you know, DBT, you know, of therapy group. So that might not be a possibility. Through some working, so through psychotherapy and counseling, you know, Ace can build skills, but it's likely that they may be on a cycle that continues towards poor coping skills, including using drugs, alcohol, and sexual behavior. So there's some key risks. Next. So one of the things, this is very much when we look at a case. This case is a non-binary case. This case is a non-binary youth. And we look at what are the larger social things that need to be attended to. Ace's story is far from uncommon in the trans and non-binary community. A 42% of trans adults report a history of self-injury. A 40% have attempted suicide. In addition to experience self-injury and suicide, Ace is missing important developmental milestones associated with school, peer and family development, social support. And it places Ace at risk for unemployment, homelessness, and a whole host of other risk factors. All the while, it's important that when we're managing all of those other distressful environmental factors, that we don't over-pathologize just the experience of TGMB individuals. Because some of those would remain constant even however Ace was identifying. So working with Ace to ensure that they're actually able to work and cope with what's around them is the first starting place. We want to help in using the GALA model to build resilience through helping them manage emotional dysregulation without the result of self-harm. We want them to build the skills over time, really learn about their environment, draw in other interdisciplinary teams or tools like employment, workforce. I mean, Ace has a pretty unregulated schedule. Something to really help structure and frame for the individual. And hope that over time, the skills that we build in emotional dysregulation management become automatic. So pulling from the case study, how do organizations and how do we represent and both create more TGMB and TGNC centered and inclusive ecosystems? We've done this both at my organization and others through research, education, and training. And so for Howard Brown, and I'll show some other model programs, we do this by first through research and respecting the welfare and rights of TGMB participants. And we strive to represent the results as accurately as possible. We avoid misuse or misrepresentation of findings. Bear in mind, the case study that I just had could very well correlate TGMB identity of the case with the negative health outcomes. But we really have to pull back the onion and look at all the ways in which the identity is interacting or intersecting with the complex environment around ACE. So another way that I think institutions are shifting with education is to use more complex documentation for intake, sex versus gender versus gender identity, recognizing the intersectionality of multiple identities when looking at an individual presenting with mental health concerns, and preparing and drawing on multidisciplinary teams, particularly integrating more cultural competency within the workforce of individuals, providers, social service providers, and clinicians who will work with individuals who identify as TGMB. Here's a quick scan that individuals can do. We can think about where our own home institution is or where our organization stands on their first, their gender literacy. Are we equipped, informed, educated to integrate all of the multidimensions that we've just presented into the organization? A question one folks participating can ask is what does your organization, whether it's your clinic or health department do to augment culturally inclusive systems that focus on the needs and experiences of TGNC individuals? And if shifting from that, you can think what could your organization be doing? Howard Brown Health and I know Thresholds and other institutions have extensive training involved in gender appropriate language, gender inclusive care, and really centering around the multidimensional and socioecological needs of TGNB individuals. So lastly, I just want to highlight one of the model programs that does use the evidence-informed practices and core components, and that is Chicago House and Social Service Agency. In particular, their Trans Life Care Program, which provides not only free healthcare, but social services to individuals who identify as trans, non-binary, and genderqueer. So Chicago House offers not just healthcare, but they expand beyond. And so we were talking about the broader ecosystem. They have onsite healthcare, they have sexual health screeners, they have legal counsel, case management, employment and housing services as well. So really attending to the whole ecosystem of factors that contribute to trans and non-binary health. The drop-in centers address the current kind of most basic needs, but also more trans-specific healthcare needs as well. The TLC is designed to provide both essential care, like I said, but also the wider net of structural effect and social factors that contribute to trans health. And you can find them there at chicagohouse.org. Some additional models and resources that folks can look at. The Trevor Project, Trans Equality, OHSU's model, the Trans Care from UCSF Center for Excellence, Fenway, Lurie, and APA all have resources here to use more expansive models for trans care. Okay, thank you so much for such an interesting presentation. Before we shift into the Q&A, I wanna take just a moment to 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 skills and even submit questions directly to our team of SMI experts. Download the app now at smiadvisor.org slash app. So we're gonna move into the Q&A. We'll try to get through as many as possible. The first question, two easy resource questions. So firstly, a few people did not catch the book of case examples that Ace was in. Could you please provide us with that so people can go ahead and look that up? Yes, we can. If we put it in the chat, will it be received? Yeah, why don't we do that? Go ahead and put that in the chat. And then the second question. Shireen, I think it's also listed on the slide at the bottom in the slide deck on the starting the case of Ace. I think in the chat, it'd be great. And then it's also, I believe, on the bottom of the slide. Okay, cool. So if people download the handouts, it'll be on there. A couple people were interested in checking the book out. So another question related to resources. So we talked about the gala approach. So where could somebody learn more about the gala approach? And do you need to be specifically trained in that? Is there some type of certificate or can you learn about it and begin practicing that type of therapy? That gender-reforming lifespan approach is a theoretical approach that's been developed through our cousin, the American Psychological Association. And I can provide to you a resource about that model. And it's not really something where you would get specific training because the idea is that foundationally in mental health and many of the disciplines we are here as a multidisciplinary workforce, we have those skills. And if we put the lens of development on gender and think our gender when we're 10 is not necessarily the gender we have when we're 20 or 50. And just remember that developmentally, we continue to change and that's something we should be applying to gender across the lifespan. And I would argue, I think Brandon alluded to this, is that this is not necessarily just for trans or gender non-binary people. Gender changes across the lifespan potentially for everyone, maybe not from cis to transgender, but people may feel differently about how they present themselves or their maleness or femaleness across the lifespan. And so I can definitely provide resources to that approach. Thank you. Okay, great. I'm trying to keep up. We're getting a flood of questions right now. So I think a few people are curious particularly about ACE in the case example. So what approach would, what were some specific interventions that a clinician could do in order to work with ACE? Do you have any suggestions around that? Sure, so I think a lot of this is stress management. Most of it is, I think working to identify things that are first triggering. I think we could, myself I could guess. So the father's mispronoun and misuse, that's going to be triggering. So recognizing some of that and helping ACE identify some of those things that trigger. I think, even as basic as creating some structure around their day-to-day, watching TV and playing on the internet is not the best structure for the individual and feels very isolating. So managing some of that, even we've found through Chicago House and Howard Brown, workforce development, helping, even for folks who've left high school, getting involved in the workforce and finding some trans-inclusive workforce development programs would be key. So some of it are just some programmatic support in addition to individual coping. At what age would you recommend introducing gender identity and fluidity? And yeah, is there any recommendation based on your experience or research at what point you should start to talk about this with children? It's a great question. I was like, either Lisa or I. Well, we talk about gender as early as before they're born, as Lisa said with the gender reveal party. I think in the same way we talk about gender literacy and having a gender spectrum is important. I think there are ways and there are books for even as young, three years old, to talk not so much about the specifics of non-binary identity, but talking about, and we do this a lot with children, behavioral gender fluidity and behavior. And there's this old books like, boys can play with dolls and things like that. All of those kind of components are helpful, I think, in creating space for gender expansive children as well, just in having an environment that makes possible more than just rigid gender roles. And one quick thing I would add to that is, try to look and encourage people to not be as excluding or punitive even. You know, if you have a young boy child and they learn to knit and they like it, you know, that doesn't necessarily have to be negative. And so when children of either gender pick a task that they may not fully understand is or is not available to them, but they like it, and then they get feedback that it's not for them, that creates discontinuity for them because now they have this thing they like and enjoy, but they're being told it's not really an access for them. And so try to embrace the fact that, you know, people can like things just because they're likable and they're not, you know, only available to one set or the other. Great. So is it preferred or necessary for a counselor or clinician to identify as TGNB? And if not, how can I, as somebody who doesn't provide any quick tips on providing effective counseling to make sure it's inclusive and safe? Sure. Yeah, I think numerically prevalence would not allow for only TGNB counselors to provide care. So the likelihood that, you know, cisgender individuals will provide care is very high. I think there's a lot of, you know, self-guided reading and training and programs like this that will help really, you know, an openness. WPATH, which is another resource that, you know, can be looked at. The really openness, again, as we've, you know, I think we've both said, you may not be treating, you may be treating a trans or non-binary person, but that's not what you're treating. You may be treating the distress, depression, or anxiety. And in that way, anyone could be, might, you know, should be competent in providing that type of counseling or psychotherapy. Okay, so we still have a lot of questions, but we unfortunately are out of time. I would suggest for people who did not get their questions answered, submit a consultation through the SMI Advisor website, and then, oh, there's that slide. If you do have follow-up questions, we can, if you submit them through then, we will have one of our experts respond. I know there were a lot of great questions, and I apologize that we couldn't get to many of them. So any mental health clinician can submit a questionnaire and receive a response from one of our experts, and they are free and confidential. SMI Advisor is proud to partner with the American Psychiatric Association on the Mental Health Services Conference, which takes place on October 14th and 15th. The keynote address at this conference features Dr. Miriam Delfin-Rittman, the newly appointed Assistant Secretary of Mental Health and Substance Use for HHS and the Administrator of SAMHSA. The conference agenda features topics such as climate change and mental health, sociopolitical determinants, structural racism, mental health in rural and indigenous populations, and much more. I encourage you to learn more and register now at psychiatry.org slash MHSB hyphen SMI. 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 can take up to five minutes. You'll then be able to select next to advance and complete the program evaluation before claiming your credit. And please join us next week on October 8th as Dr. Deb Pinals and Marvin Schwartz present Psychiatric Advance Directives, a Tool for Improving Crisis Care. Again, this free webinar will be October 8th, 2021 from 12 to 1 p.m. Eastern Standard Time. Thank you for joining us and until next time, take care.

Inclusive Evidence-Based Practices

Gender Non-Binary Mental Health Services

SMI Advisor

Dr. Lisa Rosano

Dr. Brandon Hill

Gender Identity

Gender Dysphoria

Stigma

Social Determinants of Health

GALA Model