SB829 – INTERVENTION DESIGN TO REDUCE DISPARITIES
Increasing Transgender Cultural Competency
in School Psychologists and Social Workers
A. L. LeClerc
5/13/2012
Intervention Introduction
Suicide is a major health problem among young adults in the United States. Suicide mortality is
the second leading cause of death among 15-24 year olds.1 In addition, 100-200 suicide attempts are
made per completed suicide among adolescents.2 Within this population, transgender young adults are
at particular risk for suicide mortality. Studies have reported 26-47% of transgender adolescents have
attempted suicide at least once.3,4,5 To address this dangerously high burden of suicidal behavior, the
intervention outlined in Assignment 1 was designed to reduce suicidal behavior by targeting individual
and environmental factors that increase risk for suicide among transgender youth.6 The circumscribed
time-scale and budget – 2 years and $100,000 – required of this proposal necessitates the focus of the
intervention on one outcome delineated in the outlined intervention – Environmental Outcome 3.0 (see
Appendix 1.)
This environmental outcome describes the development of accessible and culturally-competent
behavioral health care offered by school psychologists and social workers for transgender students.
Thus this intervention will provide transgender cultural-competency training to school psychologists and
social workers. The high percentage of transgender youth who reportedly seek out care from school
psychologists and social workers for mental health issues (50%) points to this professional population’s
importance in treating and preventing suicidal behavior among transgender youth.7 However,
transgender young adults often voice attitudinal barriers to seeing mental health care – perception of
identity pathologizing and distress minimizing – and the sharp decrease in care seeking past for these
students past the first visit points to the need for increased competence of psychologists and social
workers who aim to help students in the transgender community.7,8 What follows is the description of
an intervention to increase school psychologists’ awareness of transgender-specific needs, barriers to
help-seeking behavior, and overall competency in treating young adult members of the transgender
community.
Intervention Scope – Target Population & Impact
This intervention targets school psychologists and social workers who practice in Boston Public
Schools, which includes municipally-managed charter, pilot, an alternative education schools. Though
the greatest burden of suicidal behavior remains among high-school aged transgender students, the
intervention targets behavioral health professionals from all Boston public schools. Since young adults
are exploring gender identity and/or receiving diagnoses of gender identity disorder at increasingly
young ages, including professionals from elementary and middle schools ensures that all children will
have access to competent care irrespective of age.9 As of 2009, the Boston Public School system
employs 72 psychologists and social workers on a full-time and part-time basis across its three zones –
East, West, and North.10 While this intervention aims for 100% impact with all school behavioral health
professionals undergoing training, a more realistic estimate of 85%, which allows for non-participation
due to illness, scheduling conflicts, and position vacancy, is the impact goal.
Individuals aware of the intervention will include all targeted behavioral health staff of Boston
Public Schools, the Boston Public Schools board, school administrators, school LGBTQ Alliance groups,
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and members of Boston community LGBT organizations. LGBTQ Alliance student groups and community
LGBT groups will be made aware of the intervention due to the need for transgender youth participants
for pre-implementation focus groups as well as youth and adult volunteers to serve as community
representatives in trainings. Thus, we estimate conservatively that ~5,000 individuals will be aware of
the intervention (See Appendix 2 for estimate breakdown.)
Intervention Description
The cultural competency training described below has been adapted from the Fenway Institute’s
training module on transgender health needs, Understanding the T in LGBT, and specifically tailored to
behavioral health professional needs using the Association for Lesbian, Gay, Bisexual, Transgender
Issues in Counseling (ALBGTIC) Competencies for Counseling Transgender Clients.11,12 The transgender
cultural-competency intervention trainings will take place over two days. Each two-day training will be
four hours long and include no more than 15 psychologists or social workers so as to preserve feasibility
for discussion and person-to-person role playing of clinical interactions with patients. A total of six
trainings will be offered over a two month period spanning the fall semester, two trainings at a high
school location within each of the three Boston school zones. Multiple training sessions will be offered
in different geographic locations so as to increase the likelihood that all members of the target
population will participate in spite of schedule or travel limitations. Each training will be conducted by a
psychologist with experience treating transgender youth, as well as an adult volunteer from the
transgender community. A transgender student volunteer will also aid in the delivery of the training,
but only on during the first day’s program.
The first day of training will be an introduction to the transgender community in general and
focus more specifically on the behavioral health risks of transgender individuals, and especially youth.
The day will be split into two parts: the first, a mainly informational lecture and PowerPoint
presentation (2 hours,) and the second, a personal, narrative reflection on the earlier topics by both the
adult and youth volunteer (1 hour.) A final question and answer period will complete the first day’s
program (1 hour.) The main topics covered during this section of the intervention will include:
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Definitions of sex, sex role, gender, gender identity, gender expression
Definitions of non-conforming gender identities – genderqueer, agender, transgender,
transsexual
Demographics of the transgender population
History of medical and psychological diagnosis and treatment of transgender individuals
Population-specific health risks – sexual and physical violence, substance abuse, suicidality,
mood disorders, and HIV/AIDS
Behavioral health risk among transgender adolescents – rates of suicide ideation and
attempt, school harassment and violence, family rejection and instability, substance abuse,
and homelessness
The second day of training will focus more specifically on the needs of transgender youth in a
behavioral health care setting, as well as barriers to their seeking care. Best practice guidelines for
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behavioral health professionals treating transgender youth will also be discussed. This section in
particular will be heavily informed by data garnered from the transgender youth focus group on
behavioral health. The first part of the day will once again be informational and delivered through a
lecture and PowerPoint presentation (2 hours.) The second part of the day will focus on structured rollplaying scenarios in which psychologists and social workers act out therapeutic interactions with young
adult transgender clients to contextualize, synthesize, and apply the information amassed via lectures
and discussions (1 ½ hours.)
The role-playing sessions will be performed in groups of two professionals who will each have a
chance to act as both the behavioral health professional and the transgender student. The intervention
psychologist and adult representative of the transgender community will circulate and provide feedback
to professionals throughout the activity. A period of discussion of questions and issues raised during
role-playing will follow. The training will come to an end with a description of resources available to
both transgender individuals and the professions who treat those (½ hours.) Topics covered during this
section of the intervention will include:
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Recognize influence of dominant cultural notions of gender and sex roles on interactions
with and assessment of clients and planning of therapeutic intervention
Community perceptions of medical/ psychological pathologizing of transgender identity
Importance of gender inclusive and affirmative language with clients
Negotiating confidentiality – parental rejection/abuse based on transgender identity
complicates discussing treatment with guardians
Maintaining a holistic attitude – transgender identity complicates but does not erase other
needs of a developing adolescent
Responding to harassment – address bullying and harassment of transgender students
seriously and quickly with school administrators and teachers
Intervention materials to be provided to participants will include a binder containing the
PowerPoint presentations delivered over the two days in addition to the ALGBTIC guidelines for
providing transgender culturally-competent behavioral health care and a list of transgender-specific
resources and organizations in the Boston area. Since trainings will take place during the day, breaks
between the first and second parts of each day’s activities will include a provided lunch. Intervention
staff will lunch with participants, thereby allowing an opportunity for informal discussion of the
information presented.
Intervention Sequence
The shape of the academic calendar year, which begins in early September and ends mid-June
necessarily informs the sequence of intervention activities. Please see Appendix 3 for a detailed
explanation of the intervention timeline. The intervention to increase cultural competency among
school psychologists and social workers will follow a four phase plan – planning, focus group
implementation, intervention implementation, and evaluation. Planning will include three months of
stakeholder outreach and staff hiring. Six months of focus group implementation will follow planning.
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Focus group implementation will include recruiting and enrolling participants, training intervention staff
in focus group protocols, conducting focus groups, and analyzing data garnered.
Intervention implementation will proceed for the nine months following focus group
implementation. Intervention implementation will include final tailoring of intervention materials and
training manuals using data from focus groups, training intervention psychologists and transgender
volunteers, conducting cultural competency trainings, and collecting process evaluation data in the form
of pre- and post-intervention assessments, and impact evaluation data in the form of psychologist selfreported and transgender client-reported frequency and comfort with addressing transgender identity
and needs in behavioral health care sessions. Six months is provided for collection of impact data to
increase number of data points since the total number of transgender students seen by psychologists
and social workers is likely to be small and infrequently assessed. Evaluation of process and impact
outcome data will occupy the final three months of the propose two year intervention.
Intervention Budget
Specific details of the propose budget can be found in Appendix 4. However, specific choices
and assumptions regarding spending will be explained here. First, the intervention will be conducted
under the management of the Boston Public Health commission, and therefore costs for overhead,
office space, office materials, and the project coordinator’s salary will be provided by the commission.
Second, as the cultural competency trainings will be held during school hours on school premises, there
will be no cost for training space. The public health promoter will be a part-time position to reduce cost
and as a reflection of the limited scope of the intervention. To further reduce cost, the data collection
and intervention material development will be performed by an unpaid student intern from a local
school of public health.
Major costs will be incurred by paying the part time intervention psychologist and evaluator.
The cost-intensive choice of an intervention psychologist was chosen to increase the cultural similarity
and perceived authority of the implementer among the target population which is made up of fellow
psychologists and social workers.13 Since the evaluation makes up only the final three months of the
intervention, the evaluator will be hired on contract for that time. Printed intervention materials,
including copies of the intervention presentations and behavioral health professional guidelines, will be
provided to allow participants to refer to these materials as needed at a later date. Focus groups and
intervention staff trainings will be performed at the Boston Public Health Commission offices, and thus
no budget item exists for space for these events. To compensate focus group participants for their time,
iTunes gift cards will be provided and have been budgeted.
Intervention Evaluation
Needs Assessment
Focus groups conducted among transgender young adults and members of the target
population will inform specific tailoring of the cultural competency package adapted from the ALGBTIC
guidelines and merged with existing clinician training provided by the Fenway Institute.
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Process Evaluation
Baseline and post-training assessments of cultural competency will be collected from all
participants in the intervention trainings. Questions to be used in assessments will be taken directly
from points highlighted verbally and in printed training materials.
Impact Evaluation
Impact goals for evaluation will be defined as the frequency with which school psychologists or
social workers address gender identity as part of the standard initial assessment of a youth which seeks
out or is referred to school behavioral health services over the 6 month period post intervention.
Additionally, students who identify as transgender/ differently gendered/ or questioning their gender
identity and are seen by a school behavioral health professional will be given an anonymous survey
which asks about the student’s perception of the professional’s cultural competency.
Outcome Evaluation
An outcome evaluation for this intervention would measure the rate of suicide attempt and
ideation among Boston high-school students who identify as transgender to determine if these rates
change with the introduction of the intervention. At present the Youth Risk Behavior Survey conducted
in Boston schools does include assessments of suicidal ideation and suicide attempt, but does not assess
transgender identity. Ideally, a measure of gender identity should be added to the YRBS in Boston,
allowing for surveillance of suicidal behavior among the transgender adolescent population in Boston.
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References:
1. Centers for Disease Control and Prevention (CDC). Web-based Injury Statistics Query and
Reporting System (WISQARS). 2009. Available at http://www.cdc.gov/injury/wisqars/index.html,
Accessed 24 February 2012.
2. Goldsmith SK, Pellmar TC, Kleinman AM, Bunney, editors. Reducing Suicide: A National
Imperative. Washington, D.C.: National Academy Press; 2002.
3. Clements-Nolle K, Mrax R, Katz M. Attempted Suicide Among Transgender Persons. J Homosex.
2006;51:53-69
4. Grossman AH, D’Augelli AR. Transgender Youth and Life-Threatening Behaviors. Suicide Life
Threat Behav. 2007;37:527-537.
5. Mutanski BS, Garofalo R, Emerson EM. Mental Health Disorders, Psychological Distress and
Suicidality in a Diverse Sample of Lesbian, Gay, Bisexual and Transgender Youths. Am J Public
Health. 2010;100:2426-2432.
6. LeClerc A. Reducing Suicidal Behavior in Transgender Youth. 13 March 2012.
7. Greytak EA, Kosciw JG, Diaz EM. Harsh Realities: The Experiences of Transgender Youth in Our
Nation’s Schools. New York, NY: GLSEN; 2009.
8. Grossman AH, D’Augelli AR. Transgender Youth: Invisible and Vulnerable. J Homosex.
2006;51:111-128.
9. Giordano S. Lives in a Chiaroscuro. Should We Suspend the Puberty of Children with Gender
Identity Disorder? J Med Ethics. 2008; 34: 580-584.
10. Boston Herald, Inc. Your Tax Dollars at Work: Boston Payroll 2009 – Boston Public Schools
Counselors. 2009. Available at http://www.bostonherald.com/projects/payroll/boston/last.ASC,
Accessed 29 April 2012.
11. The Fenway Institute. The Fenway Guide to LGBT Health – Understanding the T in LGBT: A Guide
for Clinicians. 2009. Available at
http://www.fenwayhealth.org/site/DocServer/Module_7_Understanding_the_T_in_LGBT.ppt?d
ocID=6241, Accessed 29 April 2012.
12. Association of Lesbian, Gay, Bisexual, and Transgender Issues in Counseling. Competencies for
Counseling with Transgender Clients. 2009. Available at
http://www.counseling.org/Resources/Competencies/ALGBTIC_Competencies.pdf, Accessed 29
April 2012.
13. Bartholomew LK, Parcel GS, Kok G, et al. Planning Health Promotion Programs: An Intervention
Mapping Approach. San Francisco; Josey-Bass: 2011
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Appendix 1: Logic Model of Change to Reduce Transgender Youth Suicidal Behavior
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