Monday, September 7, 2020

Research Analysis of Transgender Adolescents

Introduction

Adolescence is a formative time for most who experience it.  The body’s physicality changes, hormones rage, hearts beat in time to their first true loves.  No matter one’s race, religion, or socio-economic status, the changes felt by youths ages 12-18 are chock-full of angst and wonder.  For some, though, the challenges may feel heavier, and, in fact, they may also actually be heavier.  One such group is adolescents who identify as transgender, an “umbrella term” for all gender-variant people.  This definition is “a useful starting place, but it obscures many complexities of transgender identity.  It makes it seem as if each transgender person has a gender that is fluid and constantly shifting, a notion which is incorrect” (Weiss, 2009, p. 27).  Also well established is that “gender is a socially constructed expression that will vary cross-culturally” (Arenas, et al., 2016, p. 20). There is no one way to be transgender or gender-fluid and adolesence is a time where such identity exploration may guide the way for a teenager’s understanding of who they are.


Academic study of transgender populations remains in its infancy, but some data has been collected.  Ten years ago, estimates showed that people who identified as transgender made up roughly 1% of the population (Weiss, 2009).  More current data reflects that 0.6% of the adult population (Hutchison, 2019) and 0.7% of those ages 13-24 (Crissman, Czuhajweski, Moniz, Plegue, and Chang, 2019) declare themselves under the transgender umbrella.  What this shows is that more research is needed to firm up these numbers and have a solid understanding not only of how many people in the United States are part of this minority group but also how better to understand and serve their community needs.  For the purposes of this paper’s discussion, focus will remain on transgender adolescents and their ability to participate as they choose in both public and private spaces.


Five salient domains of adolescent development

Physical/sexual

Many transgender people are in disharmony with their physical bodies.  Either they experience a gender-fluidity that does not clearly land them in the socially constructed gender binary of male or female or they do experience consistency, just not with the gender they were assigned at birth (Hutchison, 2019).  For these adolescents, the standard physical changes that accompany puberty have the potential for devastating effects.  While not all transgender youths associate physical sex characteristic as part of their gender identity, many do, so developing breasts, starting a menstrual cycle, deepening voice, or growth of an adam’s apple may cause unwarranted anguish for a transgender adolescent.  According to Abel (2014), pediatric endocrinologiest have been treating gender dysphoria, the DSM-5 classification for transgender individuals, with puberty-suppressing drugs as well as cross-sex hormone therapies for more than two decades.  


Most medical professionals prefer the less-risky option of puberty suppression over the implementation of cross-sex hormones for concrete reasons: cross-sex hormones yield permanent results and may result in infertility (Abel, 2014). Gonadotropin-releasing hormone therapy (GnRH), on the other hand, allows adolescents to “buy time” to consider the next possible steps and has been supported widely by medical institutions since 2009 because they are deemed free of long-term harm (Abel, 2014).  Research shows that gender dysphoria can be diagnosed as young as three but that only 10-20% still identify as gender-fluid when they reach full maturation (Abel, 2014). Therefore, an implementation of GnRH when the first signs of puberty begin to occur is a compassionate response to an adolescent who simply needs more time to understand their true identity.   Hutchison (2019) reports that around the age of 16 is when gender-affirming hormones could begin, though each case is handled on the terms of what the adolescent expresses as a best practice for their own development.  


There are a number of health care options available to transgender youth, especially those who qualify for the DSM-5 diagnosis of gender dysphoria.  For those who don’t, however, or those whose insurance doesn’t cover the necessary treatments, out-of-pocket expenses can cost $100/month for hormonal therapy and over $100,000 for some comprehensive transition procedures (Gonzales and Henning-Smith, 2017). While most medical professionals would not perform gender reassignment surgery on a transgender youth (Abel, 2014), placing the financial strain of the hormone therapies on that youth’s family could prove to be too high a price, thus denying them sufficient care.  Even when insurance hassles are not a factor, approximately one-third of transgender individuals reported a negative experience with medical professionals with reasons ranging from refusal of care to verbal/physical harrassment to having to teach providers about transgender health care” (Gonzales and Henning-Smith, 2017). The medical field seems to be waking up more to this issue, however, as pediatricians are a growing population of key advocates for transgender adolescents as they experience a growing number of cases related to physical and sexual assualts among this vulnerable population (Murchison, Agénor, Reisner, & Watson, 2019).


Ultimately, the healthcare field should be a place that is safe and accessible for all humans and not a place to experience shame or discomfort.  For transgender youth, having quality and compassionate care can make all the difference as they make decisions about how to pursue questions around possibly postponing puberty. Being denied such care could result in extremely harmful developmental consequences.


Cognitive

As Giedd (2015) so eloquently phrases it, “MRI studies show that the teenage brain is not an old child brain or a half-baked adult brain; it is a unique entity characterized by changeability and an increased networking among brain regions” (p. 33).  Adolescence is known to be a time where mental capabilities diversify in areas related to improved reasoning skills, abstract thinking, and meta-cognition, which is the ability to think about thinking (Hutchison, 2019).  Youths in this phase discover their minds to be massive vaults, better able to store information that will inform future interactions.  For those identifying as transgender, this heightened mental acuity makes them even more aware of the ways in which they are perceived as “other” by classmates, family members, teachers, and the community at-large.  Since there are so few nontraditional gender models for these adolescents to look to, many feel isolated in their development of self (Levitt and Ippolito, 2014). A 2012 study additionally showed that 43% of the patients who identified as transgender adolescents also presented with severe psychiatric histories (Abel, 2014).  The popular explanation for this is that gender-nonconforming adolescents experience high rates of bullying, violence, and harrassment at school and are less likely to attend college than their cisgender (or those who identify with the gender of their birth) classmates (Crissman, et al., 2019) which may result in an elevated risk for severe depression or tendencies towards self-harm or suicide (Abel 2014).


Moral/spiritual

According to Hutchison (2019), psychologists and anthropologists alike have ear-marked adolescence as a “universal great awakening” (p. 215).   What that means is it is a time of life where spirituality, which is closely linked to morality, is explored in depth.  Questions about the meaning of life, what consciousness is, and even the reality that life is not a permanent state of being -- that death is part of every human experience -- starts to percolate in the adolescent brain.  In this sense, both cis- and transgender teenagers start to think more deeply about not only themselves but how the world around them works -- and why.  For some factions of society, there are deeply entrenched moral and spiritual beliefs related to being homosexual and, tangentially, transgender, so it is sometimes unsafe for these populations to be “out” in their community.  Weiss (2009) writes, “Privately, homophobic people who unwittingly become acquainted with transgender people and later learn of their transgender status, have committed assault and murder, often claiming panic in defense of their actions” ( p. 31-32).  There is little doubt that such violence comes from a deep-seated fear of being taken in by that which their spirituality or morality deems “unnatural” or “wrong.”  


In another realm, there is an argument that a transgender person using the restroom that aligns with their gender identity violates others’ religious views.  Beyond the obvious retort that public schools are, by definition, not mandated to adhere to any religious argument for or against anything, Arenas, et al. (2016) states,  “These attitudes should be exposed as the harmful, degrading, homophobic, and transphobic sentiments that they are” (p. 22). All adolescents should be able to grapple with their spiritual and moral understandings of the world without the duress of bullying, abuse, and shaming cast by a patriarchal coloring of life’s great mysteries.


Social-emotional

Social and emotional intelligence are deeply intertwined.  Adolescent social-emotional competencies include things like self-awareness, impulse control, and the ability to recognize and manage complex feelings (Hutchison, 2019). Developing emotional intelligence allows adolescents to control mood swings, to motivate themselves, to think clearly, to empathize, and to hope (Hutchison, 2019).  For transgender youths, the ability to utilize emotional intelligence is part of what may qualify or disqualify them from being diagnosed with gender dysphoria.  The DSM-5 requires not only the expression of so-called cosmetic changes, like clothing preferences, or anatomical changes, like disliking one’s genitalia and wishing for different genitalia, but also  a demonstration of “impairment in social functioning, maintaining social relationships, or performing age-appropriate tasks” (Abel, 2014).  Adolescents with clear challenges in all of these areas may qualify for the DSM-5 diagnosis.  What such a diagnosis does is allow treatment for those who need it, especially if they have experienced “a constant barrage of harassment, abuse, and violence” so they may “receive supportive assistance to lessen their feelings of anxiety and isolation” (Arenas, et al., 2016, p. 21). 


Self-identity

One’s self or social identity is the formation of the understanding not only of where their so-called puzzle piece fits into society but also the emotional significance of that understanding.  This process happens both first hand and by witnessing others in real life or through the lens of media (Hutchison, 2019).  Research shows that children are tuned in to gender stereotypes before any other (Hutchison, 2019), so for those identify differently than the signals society presents, understanding who they are can present many challenges.  


Looking to examples in the media where gender norms are not adhered to can be quite empowering and liberating for anyone who feels “other” or perhaps even ashamed for relating to their identity as they do.  While in the past, depictions of transgender characters has been largely mocking or degrading, the last few years, especially, has offered a shift in media portrayal of gender-fluidity, empowering a generation to be proud of who they truly are.  Examples include RuPaul’s Drag Race, Transparent, and Pose.  While these programs are geared more towards adult audiences, what they achieve is teaching all viewers, regardless of their previously held beliefs on what it means to be transgender, that no matter what someone’s chosen gender identity is, humanity is at the core of everything.  


Pose is a true standout in this regard, especially given that all transgender characters are played by transgender actors and several episodes are written and/or directed by transgender individuals.  This program provides a full platform for relatable stories to be told.  According to Rayner (2018), “The show is not all sex, disco, and identity politics.  Pose presents itself, quite explicitly, as a family drama.”  Going on, Rayner writes, “Crucially, the show presents trans women not as faintly dotty comedic fall guys… but as rounded human beings.”  Shows like Pose almost effortlessly remove the stigma of being transgender by allowing viewers access to the people behind the identity.  Having such representation in pop culture is truly empowering for transgender adolescents who want to be able to look to society and look to media for touchstones and examples of what their lives feel like to them.  


Relationships with family, friends, and significant others

Family and friends

Studies show that memories of gender can go back to age three (Weiss, 2009), so for many transgender youths, their incongruence with the bodies they were born in goes all the way back to toddlerhood.  In these instances, transgender children have no difficulty articulating that they know precisely who they are and request that family members allow them to dress, play and behave in accordance with their gender identity, perhaps even renaming themselves something that “fits” better.  Vooris (2013) writes, “A lot of attention is given to the fact that gender non-conforming behavior happens before it is typically thought that children have a concept of gender” (p. 76).  What this means for supportive friends and family members of transgender adolescents is that they have likely been long indoctrinated into their loved one’s chosen gender identity.  Ideally, parents have opted to “follow the child’s lead on how they want to express their gender” (Vooris, 2013, p. 74), and having openly participated in the process, understand who their child is. By the time that youth is a teenager, who he or she is -- or who they are -- is likely well-established.


What that means for those friends and family members is that their on-going support is needed while their loved one goes through this challenging developmental phase, especially in regards to decisions made around puberty and whether or not puberty will be delayed or if hormone or surgical treatments will be considered.  


Significant others

One area where more struggles could appear is linked to sexuality and the expression related to the transgender teen’s sexual attractions.  Experiencing first love is a rite of passage for all teens, but may have a fair amount of challenges for transgender or gender-fluid youth.  Little research is available about sexual attraction by and for transgender individuals, though there is some questioning about whether there are people who are specifically attracted to transgender people.  Stallings (2015) writes, “Some writers are now theorizing transattraction and transorientation for individuals attracted to transgender men or women.  Yet even these differentiations between cisgender and transgender attraction do not provide enough of a shift to change thinking since the same problems of embodiment remain… These are all crises created by sexual and spiritual colonization” (p. 208).   Bottom line, there isn’t much known about transgender teens in relation to their romantic pursuits.  While it is accepted fact that transgender people can identify as straight, gay, lesbian, or bi-sexual, there is no discoverable hard data on how potential romantic partners feel about falling in love with or experimenting sexually with someone who is gender nonconforming.  Transgender writer and director Janet Mock reports, “We have not created a space for men to openly express their desire to be with transwomen… In effect, we are telling transwomen they are only deserving of secret interactions with men, further demeaning and stigmatizing [them]” (Stallings, 2015, p. 208).  More research is needed on this subject to better support transgender youths and their partners.


Community impact


Transgender advocacy plays an ever-increasing role in the way communities function.  In all truth, there hasn’t been a great deal of research on how the mass public views transgender rights, in general (Nownes, 2014), so that impact is sussed out in social justice flare-ups related to the cause.  While it comes as no surprise that discrimination against LGBTQ+ people stems from the fact that they are folks actively resisting gender norms (Taylor, et al., 2018), it is startling to know that, for instance, police officers in certain conservative pockets of the country may “ignore and downplay complaints by or on behalf of transgender victims” (Weiss, 2009, p. 32).  Such an alarm bell springs transgender education and advocacy into action, especially for the transgender youth at-risk for becoming victims of societal harm or neglect.


Poverty

Unemployment rates for transgender individuals is substantially higher than that of cisgender folks for a number of reasons.  Gonzales and Henning-Smith (2017) report that 32% of transgender men, 22% of transgender women, and 20% of gender nonconforming adults had less than a high school diploma, compared to 13% of cisgender adults.  Very probably linked to that stat is the fact that approximately 50% of transgender adults and 41% of gender nonconforming adults report an annual income of less than $35,000, compared to a third of cisgender adults (Gonzales and Henning-Smith, 2017). Weiss (2009) states, “Education which holds the key to social and economic success is often very difficult for young people who exhibit gender-variant behaviors” (p. 32).  When the rate of high school drop-out can be as much as 19% higher for transgender individuals versus cisgender, it becomes hard to ignore the hinderance that places on a transgender person’s ability to secure a suitably paying job.


Additionally, there is increased likelihood that employers may discriminate against hiring transgender individuals, even if they are qualified for the job.  Since current federal law does not explicitly protect transgender populations from such unfair hiring practices (Gonzales and Henning-Smith, 2017), there are no consequences for employers who refuse to onboard transgender staff members.  According to Weiss (2009), “Unemployment pushes many young male to female transgender people, particularly the young, into the shadow economy of prostitution” (p. 32), a demeaning and risky way to earn money.  For many trangender youth, especially those who do not come from supportive families, there are few other socially or politically-driven options to be of assistance and, as such, very little hope that they will rise out of poverty.


Bathroom policies

Arguably the most well-known public debate related to transgender social status has to do with the so-called “bathroom law.”  This topic became national news in 2016 when North Carolina enacted the Public Facilities Privacy and Security Act (HB2), required transgender students to use restrooms and locker rooms that corresponded to the sex on their birth certificates (Arenas, et al., 2016).  The Obama Administration swiftly responded to this by reiterating guidelines based on Title IX which prohibit schools receiving federal funding from such discrimintion, thus clarifiying that schools must allow transgender students access to the bathroom that matched their gender identity (Arenas, et al., 2016).  While the immediate uproar resulted in eleven states suing (Arenas, et al., 2016), the Trump Administration rescinded the Obama Administration’s support a year later, turning the decision back to the states and schools to make their own rules in this regard (Crissman, et al., 2019).  


While it may seem on the surface a simple or even perplexing consideration, allowing transgender adolescents access to the restroom or locker room of their choosing is both empowering and affirming.  It tells the youth that they are accepted and valued for who they are.  Forcing them to use a staff restroom, for instance, may attract unwanted attention (Murchison, et al., 2019), and requiring them to use the facility related to their gender-assigned-at-birth may have even more dire consequences.  According to Murchison, et al. (2019), a survey of 3,673 transgender or nonbinary US adolescents revealed that 26.5% of transgender boys, 27% of nonbinary children who were female at birth, 18.5% of transgender girls, and 17.6% of nonbinar children who were male at birth had been assaulted over a year-long period -- not surprisingly, the schools were the students were restricted to use the restrooms of their gender-assigned-at-birth experienced higher rates of violence against them than those who were able to choose their own restroom.  Though it is widely known to happen, data on the prevalence of sexual assault in this demographic has not yet been established, but over a lifetime, there is a 47% likelihood of such a violent attack against transgender populations  (Murchison, et al., 2019).  


Those advocating for students to use the restroom according to their gender assigned at birth argue that “being transgender is a psychological disorder that schools should not enable” (Arenas, et al., 2016, p. 21).  They also cite safety and privacy in regard to the cisgender students, lack of funds to create new signs for all-gender bathrooms, a need for the decision to made on a state or local level, effectively removing it from a national debate, and the previously mentioned religious rights argument (Arenas, et al., 2016). In a 2015 survey of 683 adolescents, 21% of the respondents advocated for restrictive use, some of them suggesting that transgender people were “unnatural, unacceptable, and pathological” (Crissman, et al., 2019).  Additionally, those against allowing transgender students to use the restroom of their choice said they would be OK with it if the student had surgery to have genitalia that matched the restroom’s assigned gender while others claimed that some of their classmates might take advantage of the restroom choice to “masquerade” as transgender merely to gain access to the restroom for predatory or perverted reasons (Crissman, et al., 2019).  


On the other side of all of these misguided rationales to restrict restroom use is a great deal of logic.  For starters, assuming someone who identifies as transgender is mentally ill creates its own kind of harm as it labels them as deviant (Arenas, et. al, 2016).  The safety argument is easily debunked, seeing as research shows that if anyone’s protection from harm should be considered, it’s that of the transgender student.  Arenas, et al. (2016), reports that a 2013 national survey revealed that 61% of transgender students where verbally harassed, 29% were physically harassed, and 15.5% were physically assaulted, and 75% of all transgender students feel unsafe in school, compared to 26% of cisgender females.  As for privacy, the mere act of having to get undressed in a locker room, for example, has the potential to violate all students’ privacy, not just cisgender students.  With regard to the cost burden of changing restroom signage, it’s easy to debunk that as a truly prohibitive, since changing out a couple of plaques wouldn’t require large funds.  And to the question of leaving it up to each state to decide, former US Attorney General Loretta Lynch said, “It is about dignity and respect we accord fellow citizens.  It’s about the founding ideals that have lead this country --  haltingly but inexorably -- in the direction of fairness, inclusion, and equality for all Americans” (Arenas, et al., 2016, p. 24).  According to Crissman, et al. (2019), many of this country’s youth agree, as 79% of the 683 youth were in favor of allowing transgender students to use the restroom of their choice.  For these adolescents, they said they believed bathroom use is private, that being able to choose a bathroom was a matter of equality and human rights, that they wanted to affirm that being transgender did not make anyone a pervert or a predator, and that forcing their transgender classmates to use a restroom not of their choosing could put them at risk for bullying and violence (Crissman, et al., 2019). 


The silver lining here is that the overwhelming majority of that school-aged sample was in favor of transgender rights and protections.  The souring reality, though, is the sample size is very limited and more encompassing surveys and research need to be conducted to ensure that transgender rights are being discussed, understood, and dealt with in schools to better protect this vulnerable population.  





References


Abel, B. S. (2014). Hormone treatment of children and adolescents with gender dysphoria: an ethical analysis. Hastings Center Report, 44(s4), S23-S27.


Arenas, A., Gunckel, K. L., & Smith, W. L. (2016). 7 reasons for accommodating transgender students at school. Phi Delta Kappan, 98(1), 20-24. Phi Delta Kappa International.


Crissman, H. P., Czuhajewski, C., Moniz, M. H., Plegue, M., & Chang, T. (2019). Youth Perspectives regarding the Regulating of Bathroom Use by Transgender Individuals. Journal of homosexuality, 1-16.


Giedd, J. N. (2015). The amazing teen brain. Scientific American, 312(6), 32-37.


Gonzales, G., & Henning‐Smith, C. (2017). Barriers to care among transgender and gender nonconforming adults. The Milbank Quarterly, 95(4), 726-748. Milbank Memorial Fund.


Hutchison, E. (2019). Dimensions of Human Behavior. Los Angeles, CA: Sage.


Levitt, H. M., & Ippolito, M. R. (2014). Being transgender: The experience of transgender identity development. Journal of homosexuality, 61(12), 1727-1758.


Murchison, G. R., Agénor, M., Reisner, S. L., & Watson, R. J. (2019). School restroom and locker room restrictions and sexual assault risk among transgender youth. Pediatrics, 143(6), e20182902.


Nownes, A. J. (2014). Interest groups and transgender politics: Opportunities and challenges. Transgender rights and politics: Groups, issue framing, and policy adoption, 83-107. University of Michigan Press.


Rayner, A. (2018). “Strike a Pose: Why Ryan Murphy’s new show about voguing is TV atits most fearless.” The Guardian. Retrieved from https://www.theguardian.com/culture/2018/aug/25/pose-ryan-murphy-new-show-about-voguing-is-tv-at-its-most-fearless


Taylor, J. K., Haider-Markel, D. P., & Lewis, D. C. (2018). Rise of the Transgender Movement and LGBT Rights. The remarkable rise of transgender rights, pp 26-57. University of Michigan Press.


Vooris, J. A. (2013). Trapped in the wrong body and life uncharted: anticipation and identity within narratives of parenting transgender/gender non-conforming children. Chasing rainbows: Exploring gender fluid parenting practices, 72-89.


Weiss, J. T. (2009). Teaching Transgender Issues. A Twenty-first Century Approach to Teaching Social Justice: Educating for Both Advocacy and Action, 358, 27.



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Research paper written while in pursuit of my MSSA (2019)


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