Introduction
The mental and physical health profiles of transgender and gender expansive (TGE) youth must be contextualized in the social, structural, and political circumstances in which TGE youth are situated. Individuals whose gender is assigned coercively at birth, including transgender, nonbinary, and genderqueer people, are disproportionately burdened by trauma related to interpersonal, self-directed, and collective violence (Richmond, Burnes, & Carroll, 2012). For example, in the largest known community based survey of nearly 28,000 TGE people in the United States, nearly half experienced verbal harassment and/or physical assault (48%) as well was nearly half who experienced sexual assault in their lifetime (47%) (James & Herman, 2017). In addition, the survey found a 40% suicide rate among the population, an estimate nine times higher than the overall US suicide rate. Finally, historical collective violence such as traumas experienced in public and within institutions (such as health care, education, law enforcement, and politics) spans across generations but is only recently becoming more known (Asakura, 2017; Richmond et al., 2012).
While there have been great advances in informing the public on diverse gender experiences, many of these efforts further marginalized genderqueer and nonbinary identities (Beemyn, 2015). For example, unique gender experiences of genderqueer and nonbinary people are often excluded from transgender rights movements (Beemyn, 2015). In addition, genderqueer and nonbinary individuals remain largely absent from research (Darwin, 2017), which has almost exclusively focused on binary gender identities (Budge, Rossman, & Howard, 2014). Furthermore, in instances when research studies offer gender options beyond the binary, genderqueer and nonbinary participants are often grouped with binary transgender participants in a broad sexual and gender diverse category or grouped with binary transgender participants in explicitly gender diverse studies. This aggregated approach to inquiry limits the generalizability of findings and neglects experiences of genderqueer and nonbinary communities who face unique socio-structural challenges rooted in binarism. To better understand the research landscape of genderqueer and nonbinary communities in the United States, this paper will apply dimensions of the Gender Minority Stress and Resilience framework (Hendricks & Testa, 2012; Testa, Habarth, Peta, Balsam, & Bockting, 2015) for organizing the review of literature on stressors, resilience, and the physical and mental health outcomes encountered by genderqueer and nonbinary communities. Implications for gender affirming social work research, practice provision, and policy with genderqueer and nonbinary communities are discussed. Guided by an Intersectional (Crenshaw, 1989) and Gender Minority Stress and Resilience (Hendricks & Testa, 2012) frameworks, this chapter will provide information about trauma and resilience among TGE youth and discuss implications for affirmative social work practice, research, and policy with TGE youth.
Intersectional and Gender Minority Stress, Resilience Frameworks
Intersectionality is a framework coined by Kimberle Crenshaw, a Black feminist scholar (Crenshaw, 1989). This framework recognizes the interconnectedness of systems of oppression (e.g., racism, classism, ableism, heterosexism, and xenophobia) and how these systems work simultaneously to privilege or disadvantage certain groups of people (Crenshaw, 2017). Furthermore, the systems of oppression are enacted interpersonally, institutionally, and politically. The oppressions are known to contribute to economic, health and housing adversities disproportionately impacting individuals who belong to historically socially stigmatized groups, such as Black women of transgender experience, Latinx gender non-conforming people, and gender expansive youth who are Black, Indigenous, and people of color (BIPOC).
Another and less studied system that is harmful to TGE youth is binarism. Binarism is a set of attitudes, beliefs and actions that classify ideas, objects or systems (such as gender, race, sexual orientation or political ideology) into two, often opposing, categories (Alizai, Doneys, & Doane, 2017; He, 2014). Known as a colonial mechanism to establish hierarchies and dominance within racial, gender, sexual, and other social groups, binarism acts as a system of oppression akin to racism, classism, cissexism, and heterosexism (Alizai et al., 2017; Hinchy, 2017). Many cultures have traditionally recognized genders that transcend a binary gender understanding – for example, fa’affafine in Samoa or and bissu, calalai, and calabai in Indonesia. However, colonial rule’s enforcement of capitalist, patriarchal, heterosexist, and binarist values have led to interpersonal, structural and political violence plaguing sexually diverse and gender expansive communities across the world (Ali, Keo, & Chaudhuri, 2020).
In the United States, gender expansive people (including genderqueer and nonbinary people) make up over one-third of the population of individuals whose gender differs than assumed at birth (James & Herman, 2017). Despite this significant representation of gender expansive people within trans communities in the United States (James & Herman, 2017; Meerwijk & Sevelius, 2017; Puckett, Cleary, Rossman, Mustanski, & Newcomb, 2018; Tebbe & Moradi, 2016), institutions such as language, media, mass incarceration, health, and education, systematically stigmatize or erase TGE communities by adopting binary gender norms (Baptista & de Loureiro Himmel, 2016; Beemyn, 2015; Factor & Rothblum, 2008; Kattari, Walls, & Speer, 2017; Pemberton, 2013; Richmond et al., 2012). This restrictive approach ignores unique experiences of gender expansive people and regularly reinforces barriers to mental health, physical health, and well-being among the population (Bith-Melander et al., 2010; Warren, Smalley, & Barefoot, 2016).
Gender Minority Stress and Resilience
The Gender Minority Stress and Resilience Model (GMSRM; Testa et al., 2015) is an extension of Meyer’s (1995) minority stress model and assesses distal stress, proximal stress, and resilience as well as their influence on mental and physical health outcomes experienced by TGE people. Testa and colleagues conceptualize TGE distal (i.e., external) stressors as mistreatment such as discrimination, rejection, non-affirmation, and violence in response to one’s gender identity or expression. Proximal (i.e., internal) stressors include internalized transphobia, expectations of rejection, discrimination, violence, or non-affirmation, as well as nondisclosure. Connectedness with TGE community and pride regarding TGE identity are considered resilience and protective factors within this framework.
Distal Stressors
TGE youth face alarming rates of interpersonal and institutional violence and exclusion from peers, family members, community, and institutions (e.g., educational, medical, religious), with higher rates among TGE youth who are nonbinary, BIPOC, or disabled (Keener, 2015). In a study of over 1,000 TGE and cisgender gay, lesbian, bisexual, and queer adolescents, higher rates of multi-traumas were reported among gender expansive individuals assigned male at birth (71.5%) and gender expansive individuals assigned female at birth (49.5%) compared to cisgender gay, bisexual, or queer young men (33.0%) (Sterzing, Ratliff, Gartner, McGeough, & Johnson, 2017). In addition, scholars have identified higher stress related to racism and transphobia among gender expansive people of color compared to their white counterparts (Kattari, Walls, Whitfield, et al., 2017). Furthermore, TGE individuals with disabilities face disability-related discrimination when accessing health, mental health, drug treatment, and crisis services (Kattari et al., 2017).
More generally, TGE young people encounter a lack of TGE affirming care from providers often leading to being referred out or being denied care (Puckett et al., 2018). As a result of routine enforcement of transphobia and a binary gender system, many TGE must use the gender assumed at birth when interacting socially and navigating institutions (Richards et al., 2016). Given the pervasive adoption of binarism across social, structural, and institutional systems, gender expansive individuals in particular often feel isolated and unwelcome in social service environments (Ansara, 2015). In addition to facing rejection within service systems, TGE individuals also encounter stressors as a result of gendered facilities such as restrooms and changing rooms. For example, a study exploring identity development, disclosure, and community relationship revealed that most (89%) gender expansive individuals experience discomfort when having to choose a gendered toilet (Factor & Rothblum, 2008).
Proximal Stressors
In Testa and colleague’s (2015) model, proximal stressors, such as internalized anti-TGE attitudes, negative expectations, and nondisclosure also have a critical role in mental and physical health outcomes of TGE communities (Testa et al., 2015). Although proximal stressors among TGE communities are less studied compared to distal stressors, researchers are beginning to examine internalized factors within TGE groups. For example, Factor and Rothblum (2008) found that genderqueer individuals were least likely to disclose their gender identity with primary health providers compared to transwomen and transmen. This difference may be due to the unique impact of binarism and transphobia on nonbinary communities compared to transgender women and...
