Course Articles

Disclosures: 

Presenter Disclosure:

• Financial: Calista Kelly is employed by Continued.com.
• Non-Financial: Calista Kelly has no non-financial disclosures.

Content Disclosure: This learning event does not focus exclusively on any specific product or service.

Sponsor Disclosure: There is no external sponsor for this course.

Limitations/Risks

• Awareness is not impact. Reading about bias can raise knowledge and self-awareness, but it does not reliably change clinical behavior or patient outcomes on its own; completion should not be mistaken for improvement in practice.
• DEI and cultural competency. Cultural-competency framing can drift toward checklist "mastery" of groups and reinforce the very stereotyping it aims to reduce, so it must be paired with cultural humility; learners should also remember that implicit bias, structural racism, cultural competency, and DEI are often separate licensure requirements, and that this is a contested space where defensiveness can undermine engagement.
• Format and assessment. As a self-paced written activity assessed by a multiple-choice test, the course measures knowledge rather than skill or team behavior, and it can only model interprofessional collaboration rather than have learners practice it.
• Data currency and fit. The statistics are time-sensitive and will need updating. Reliable data for some high-risk populations are limited or suppressed, and national figures may not reflect a learner's local patients or setting.

Learning Outcomes

After this course, participants will be able to:

• Describe implicit and explicit bias, explain how each develops through lifespan socialization and can influence interprofessional team members’ interactions with childbearing patients, and identify at least two resources team members can use to examine their own biases.
• Recognize how bias and power differentials between clinicians and patients can affect the patient and the patient and team relationship.
• Describe structural racism and how it forms, explain its impact on maternal health, and identify risk factors for and patterns of maternal morbidity and mortality across five racial and ethnic populations in the United States.
• Describe infant mortality in the United States and its ties to maternal health, and explain the interprofessional team’s role in reducing the impact of implicit bias and structural racism for pregnant patients.

Introduction: Why This Topic Belongs to the Whole Team

Pregnancy and the year that follows it are among the most medically and socially intensive periods in a person’s life, and they are also a period in which the United States performs poorly relative to its wealth. Maternal deaths in this country have remained stubbornly high, and they fall unequally. In 2023, the national maternal mortality rate was 18.6 deaths per 100,000 live births, but the rate for Black women was 50.3 per 100,000, more than three times the rate for White women (Hoyert, 2025). These differences are not explained away by income or education, nor are they a recent accident. They are the visible surface of two deeper and interacting forces: the everyday operation of bias inside clinical encounters, and the long history of structural racism that shapes who gets sick, who is believed, and who survives.

This course is written for an interprofessional audience. The perinatal team is larger than many clinicians assume. It includes obstetric and nursing staff, but it also includes behavioral health clinicians who treat perinatal mood and anxiety disorders, physical therapists who manage pelvic floor dysfunction and musculoskeletal pain in pregnancy and postpartum, occupational therapists who support feeding, infant development, and a parent’s return to daily activities, speech-language pathologists and audiologists who screen and treat newborns and follow infants at developmental risk and respiratory therapists who manage the breathing support that premature and medically fragile newborns depend on and who help care for mothers facing respiratory complications of pregnancy. Each of these professionals interacts with childbearing patients and their families, often at moments of vulnerability, and each carries the same human cognitive machinery that produces bias. A course built for only one discipline would miss the central point of this material: that bias and its consequences are a team problem and a team responsibility.

The interprofessional framing also matters because the evidence base points toward team-level change rather than individual heroics. Education planned by and for the healthcare team, in the language of Joint Accreditation, is designed to change how team members work together, not simply to update one clinician’s knowledge. The four competency domains commonly used to organize interprofessional practice, namely values and ethics, roles and responsibilities, interprofessional communication, and teams and teamwork, will recur throughout this material because reducing the harm of bias depends on all four. A physical therapist who notices that a patient’s pain reports are being dismissed, an occupational therapist who hears a colleague describe a family in stereotyped terms, or a behavioral health clinician who recognizes that a patient has stopped trusting the care team, each holds a piece of the solution, but only if the team has the shared values, role clarity, and communication habits to act on it.

This is sensitive material. Discussions of racism, bias, and preventable death can be uncomfortable, and discomfort is an expected part of learning in this area (Campbell, 2025). The goal here is not to assign guilt but to build accurate understanding and practical skill. Bias is a feature of normal human cognition, present in well-intentioned people, and the question is not whether a clinician has biases but what the team does about them. With that framing in mind, the course moves from the psychology of bias to how bias forms and operates in clinical relationships, to the structural forces surrounding those relationships, to the maternal and infant outcomes at stake, and finally to what the interprofessional team can actually do.

A word about how to engage with this material will help. The most useful posture for a learner here is neither defensiveness nor self-flagellation, but curiosity. The aim is to leave with a more accurate model of why a group of well-meaning professionals can nonetheless participate in a pattern of unequal outcomes, and with a concrete sense of which of one’s own habits and which of the team’s routines are worth changing. Where the course presents numbers, it presents the most recent national figures available and names their source, so that a reader can see that the disparities described are not rhetorical but measured. Where it makes a claim about how bias operates, it ties that claim to the research literature rather than to anecdote. And throughout, it keeps returning to the same practical question that interprofessional education is designed to answer: not what should I, alone, believe, but how should we, together, work, so that the next patient is heard, believed, and kept safe regardless of who she is.

Section 1: Implicit and Explicit Bias Defined and Differentiated

A bias, in the most general sense, is a tendency to favor or disfavor a person, group, or idea in a way that interferes with fair judgment. In healthcare, the term usually refers to attitudes about social groups that shape how a clinician perceives, communicates with, and treats a patient. Two broad categories are useful to distinguish at the outset, because they form and operate differently and call for different responses.

Explicit bias refers to attitudes and beliefs that a person holds consciously and can report. A clinician who openly believes that members of a particular group are less reliable historians of their own symptoms holds an explicit bias. Explicit biases are, by definition, available to introspection, which means they can be stated, defended, argued with, and, in many settings, socially discouraged. Most clinicians sincerely endorse the value of treating every patient equally, and on explicit measures, healthcare professionals tend to report egalitarian attitudes (FitzGerald & Hurst, 2017). That sincerity is real and part of what makes the second category so important.

Implicit bias refers to attitudes and associations that operate outside of conscious awareness and intention. These are automatic mental shortcuts: learned associations between a social group and a set of traits, evaluations, or expectations that activate quickly and without deliberate thought. Because they are unconscious, implicit biases can run contrary to a person’s consciously held, explicitly egalitarian values, and a person can be entirely unaware that the bias is influencing a decision (Campbell, 2025). This is the crucial difference. A clinician can honestly believe that they treat all patients the same and still, in the rushed and cognitively demanding environment of clinical care, act on associations they would reject if asked about them directly.

The mechanism is rooted in ordinary brain function. Implicit associations are formed through repeated exposure to messages and patterns in the surrounding culture, and they can be rapidly activated when the brain encounters socially relevant cues, producing a fast, automatic evaluation before slower, deliberate reasoning has a chance to engage (Campbell, 2025; Josiah et al., 2023). This speed is adaptive in many contexts because the brain must constantly categorize and predict, but it becomes a liability when learned associations are inaccurate and attach negative expectations to a patient based on race, ethnicity, language, body size, age, disability, or other group membership.

A widely used research tool for detecting implicit associations is the Implicit Association Test, which measures how quickly people pair concepts, on the premise that more strongly associated concepts are paired more quickly. Research using such measures has repeatedly found that healthcare professionals, as a group, show levels of implicit bias similar to those of the general population, and a systematic review of this literature concluded that such bias among healthcare professionals is associated with measurable differences in the care patients receive (FitzGerald & Hurst, 2017; Hall et al., 2015). In other words, entering a caring profession does not exempt a person from the associations absorbed from the broader culture. It is worth noting that individual scores on these tests are not a diagnosis of a clinician’s character and do not perfectly predict any single decision; the value of the research lies in establishing, at the population level, that the phenomenon is real and pervasive.

Why does the distinction between explicit and implicit bias matter for the interprofessional team? Because the two require different countermeasures. Explicit bias can sometimes be addressed through policy, accountability, and direct feedback, since the attitude is available to the person holding it. Implicit bias is not reachable in the same way, because the person is not aware of it. Telling a team to simply try harder to be fair is therefore an incomplete strategy, since the biases most likely to slip through are the ones no one intends. Effective approaches, discussed in Section 7, work by changing the conditions under which automatic associations get a chance to drive behavior, for example, by slowing decisions at high-stakes moments, by standardizing how symptoms are assessed, and by building team habits that catch what an individual misses.

It also helps to see how an implicit association becomes a clinical decision, because the pathway is rarely dramatic. Clinical reasoning depends heavily on rapid pattern recognition, the experienced clinician’s ability to size up a situation quickly, and that same speed is what allows an unexamined association to enter the judgment unnoticed. The bias does not announce itself as prejudice. It shows up as a slightly lower index of suspicion for one patient than another, a quicker readiness to attribute a complaint to anxiety or drug-seeking, a marginally shorter visit, less eye contact, fewer open-ended questions, or a faster move to reassurance rather than investigation. Any one of these is small, and any one could have an innocent explanation, which is exactly why bias is so difficult to catch in the moment and so consequential in the aggregate. Across thousands of encounters, small differences in suspicion, attention, and effort accumulate into measurable differences in the care that groups of patients receive (Campbell, 2025; FitzGerald & Hurst, 2017).

A further nuance is that implicit and explicit attitudes can point in different directions within the same person, and the relationship between what a clinician sincerely believes and how a clinician automatically reacts is loose rather than fixed. A clinician may hold strong, genuine egalitarian commitments and still carry implicit associations absorbed from the surrounding culture, and under ordinary conditions of fatigue, time pressure, and cognitive load, it is the automatic system that often wins (Campbell, 2025). This is why the sincerity of a team’s stated values, though real and important, cannot be the whole of its safeguard. Values shape the explicit layer; they do not automatically reach the implicit one. Recognizing this gap is not cynicism about clinicians’ character. It is an accurate account of how the mind works, and it points toward solutions that do not depend on individuals simply wanting to be fair.

It is also worth being precise about what implicit-bias measures can and cannot tell us, because misunderstanding this point has fueled both overclaiming and backlash. Tools such as the Implicit Association Test are research instruments that reliably detect automatic associations at the group level, and the body of evidence using them demonstrates that clinicians, like everyone else, hold such associations (FitzGerald & Hurst, 2017). What these tools do not do well is predict, with precision, what a particular clinician will do with a particular patient on a particular day. A clinician should therefore neither treat a personal test result as proof of guilt nor dismiss the entire phenomenon because the prediction at the individual level is imperfect. The defensible reading of the science is the moderate one: implicit bias is real, common among well-intentioned clinicians, and capable of influencing care, while remaining only one of several forces acting in any given encounter (Campbell, 2025; FitzGerald & Hurst, 2017).

For every profession on the perinatal team, the practical translation is the same. The audiologist interpreting a parent’s response to a newborn hearing screen, the speech-language pathologist judging whether a feeding concern warrants follow-up, the physical therapist deciding how seriously to take a postpartum patient’s report of pain, the occupational therapist assessing a parent’s engagement with an infant, and the behavioral health clinician forming an impression of a patient’s risk, are all making rapid judgments under time pressure and uncertainty, which are exactly the conditions in which implicit associations exert the most influence. None of these clinicians is choosing to be unfair, and most would be distressed to learn that an outcome had turned on an association they never endorsed. That is precisely the point. Recognizing that these everyday, well-meant judgments are vulnerable is the first step toward protecting them, and protecting them is a task that the following sections show is best carried out by the team rather than left to the individual.

It is worth naming explicitly the conditions under which an automatic association is most likely to slip past a clinician’s better judgment, because those conditions describe ordinary clinical life rather than rare exceptions. Bias tends to exert the greatest influence when a decision is made quickly, when the clinician is fatigued or stressed, when cognitive load is high, when the information available is ambiguous, and when the clinician must rely on first impressions rather than accumulated knowledge of the individual patient (Campbell, 2025). Each of these is a routine feature of perinatal care: the triage decision made in a busy unit, the late-shift assessment by a tired clinician, the brief first encounter with a patient whose history is incomplete. This matters for the team because it means that the moments of greatest vulnerability to bias are predictable, and predictable vulnerabilities can be designed around. If the team knows that the rushed, ambiguous, first-impression decision is where bias is most likely to enter, it can build in the deliberate pause, the second look, and the standard protocol precisely at those points, rather than relying on individuals to summon extra fairness at the very moments when their capacity to do so is most depleted (Campbell, 2025; Hagiwara et al., 2024; Kirwan Institute, 2013).

Bias also comes in more than one form, and a shared vocabulary helps a team recognize the particular pattern at work in a given encounter. Beyond the racial and gender bias most often discussed, the cognitive-science and healthcare literatures describe a family of related tendencies: affinity bias, the pull toward people who resemble us; confirmation bias, the tendency to notice and weight information that fits an expectation already formed; anchoring, the overreliance on the first piece of information encountered; attribution bias, the tendency to explain another person’s behavior in terms of character rather than circumstance; the halo and horns effects, in which one salient trait colors the whole impression; and name bias and bias based on perceived weight, body type, age, education, or socioeconomic status (Kirwan Institute, 2013). These are not separate phenomena from implicit bias but specific shapes it takes, and in the perinatal setting, each has a concrete cost. Anchoring on an initial impression of a patient as anxious can crowd out later physical signs; confirmation bias can lead a clinician to register findings that fit a benign explanation and discount those that do not; and weight or age bias can quietly lower the seriousness with which a symptom is treated. Naming the specific pattern is useful precisely because the countermeasure differs: confirmation bias calls for deliberately seeking disconfirming evidence, while anchoring calls for revisiting the initial assessment as new information arrives. 

Section 2: How Bias Forms: Socialization, Stereotypes, Prejudice, and "Isms" Across the Lifespan

If implicit biases are learned associations, the natural question is where they are learned. The short answer is that they are absorbed over a lifetime from the social world a person grows up in and lives in. No one is born with a fully formed set of biases, and no one chooses them deliberately. They accumulate through the ordinary process of socialization, the lifelong process by which a person takes in the norms, categories, images, and expectations of family, community, schooling, media, language, and institutions (Campbell, 2025). Understanding this process helps the team see bias as a product of the environment rather than a personal moral failing, which, paradoxically, makes it easier to confront it honestly.

Several related terms are useful to define here, because they are often used loosely. A stereotype is a generalized belief about the characteristics of a group, applied to individuals who belong to it. Stereotypes are cognitive: they are the brain’s categories and the traits it attaches to them. Prejudice is an attitude or feeling, usually negative, directed toward a group or its members. Where a stereotype is a belief, prejudice is the affective charge, the liking or disliking, that often accompanies it. Discrimination is behavior: the differential treatment of people based on their group membership. The suffix “ism,” as in racism, sexism, ageism, ableism, or classism, names a system in which stereotypes and prejudice become organized and reinforced at the level of institutions and culture, so that the disadvantage no longer depends on any single biased individual. These distinctions matter because an intervention aimed at a belief, a feeling, a behavior, or a system will look different in each case.

The lifespan dimension is important. Children absorb associations from the earliest years, often before they have the language to question them, simply by noticing patterns in who is present, who is praised, who is feared, and who is absent in their environment. These associations are then reinforced across decades by repeated exposure to the same patterns in entertainment, news, professional training, and the structure of the institutions a person passes through (Campbell, 2025). For healthcare professionals, there is a specific occupational layer to this story. Clinical training and longstanding medical literature have at times transmitted inaccurate beliefs about biological differences between racial groups, and such beliefs, once learned, can persist and distort clinical judgment, for example, in the historically documented tendency to underestimate the pain of Black patients (Josiah et al., 2023). A clinician, therefore, arrives at the bedside carrying both the general biases of the surrounding culture and any specific misconceptions transmitted through professional socialization.

It is worth dwelling on each of the key terms, because precise language helps a team diagnose what it is actually facing. A stereotype can be positive in valence and still cause harm; the belief that a particular group is unusually resilient or tolerant of pain is a stereotype, and in maternity care, a stereotype of toughness can translate directly into undertreatment. Prejudice need not be intense hostility; a faint, automatic discomfort or a reflexive lowering of warmth toward members of a group is prejudice in the sense that matters clinically, and it shapes the emotional tone of an encounter that the patient feels even when nothing is said. Discrimination, the behavioral layer, includes not only overt acts but also the quiet differentials described in Section 1, the shorter visit and the lower suspicion. And the “ism” layer is what makes the problem self-sustaining: once stereotypes and prejudice are built into curricula, guidelines, institutional routines, and the surrounding culture, they reproduce themselves in each new cohort of professionals without anyone deciding to pass them on (Campbell, 2025; Njoku et al., 2023). A team that can identify which layer it is dealing with is better positioned to choose an appropriate response.

The developmental account also explains why exhortation alone fails. By the time a person reaches professional training, decades of socialization have already laid down the associations, and a sincere adult decision to be fair operates on top of that foundation rather than erasing it (Campbell, 2025). This is not a counsel of despair. Associations that were learned can be weakened and counteracted, and the surrounding environment that produced them can be changed. But it does mean that the goal of self-examination is not to reach a state of being bias-free, which the evidence does not support as a realistic endpoint, but to become reliably aware of one’s vulnerabilities and to build the personal and team habits that keep those vulnerabilities from reaching patients (Campbell, 2025; Hagiwara et al., 2024).

The occupational layer deserves particular emphasis for a clinical audience, because it is the part of socialization that professional training is directly responsible for. Historically, medical and clinical education transmitted false beliefs about biological differences between racial groups, including the durable and damaging myth that Black patients experience or tolerate pain differently, and such beliefs, absorbed during training, can persist into practice and distort assessment and treatment long after they have been formally discredited (Josiah et al., 2023). The maternal health literature treats this history as directly relevant to present-day disparities, because pain and symptom assessment are exactly the judgments through which warning signs of serious complications are recognized or missed (Josiah et al., 2023; Montalmant & Ettinger, 2024). A team that understands this history is less likely to be surprised when a patient’s reported pain is discounted and more likely to build checks to catch such discounting.

Turning to resources, several categories support honest self-examination, and they work best in combination. Validated self-assessment and program-level instruments allow individuals and teams to measure awareness of and mitigation of bias in maternity care and to track change over time, replacing impressions with data and enabling assessment of whether anything is actually improving (Bower et al., 2023). Structured reflective practice, in which clinicians examine specific encounters and their own emotional reactions to particular patients, helps surface associations that stay hidden under the smooth surface of routine. Continuing education, including activities like this one, provides the shared vocabulary and evidence that allow a team to discuss bias without each conversation collapsing into defensiveness or blame. Confidential implicit-association measures can be a useful prompt for personal reflection, provided they are framed as conversation-starters rather than verdicts. And cultural humility, the disposition to approach each patient as the authority on their own life and to remain a learner rather than assume expertise about a patient’s experience, gives self-examination a durable orientation rather than a finish line.

Putting these resources into practice is itself a skill, and a few principles make the effort more honest and more durable. Reflection is most useful when it is specific rather than general: examining an actual encounter that left a clinician uneasy, or a particular patient toward whom the clinician felt an unexplained reluctance, surfaces more than an abstract intention to be fair. It is also most useful when it is routine rather than occasional, because the associations being examined are themselves the product of constant, lifelong reinforcement and will not be undone by a single sitting (Campbell, 2025). Carrying the work out in the company of colleagues, in a setting where it is safe to name discomfort without fear of judgment, tends to be more sustainable than solitary effort, both because others can see patterns a clinician cannot see in themselves and because shared reflection builds the team culture in which raising the subject of bias is normal rather than threatening. The aim of all of this is not the impossible one of becoming a person with no associations, but the achievable one of becoming a clinician who knows where their judgment is most likely to slip and who has built, with their team, the habits that catch it before it reaches a patient (Campbell, 2025; Hagiwara et al., 2024).

A word of realism is appropriate here, because it will recur in Section 7. The mere act of measuring or naming one’s biases does not, by itself, reliably change behavior, and some popular training approaches rest on weak evidence and have not demonstrated lasting effects on practice (Hagiwara et al., 2024). Self-examination is necessary but not sufficient. Its value lies in opening the door to the structural and team-level changes that do the heavy lifting, and in sustaining the personal vigilance those changes require. For the interprofessional team, the shared goal of this section is a common understanding: that every member arrived with biases they did not choose, that some of those biases were transmitted by the professions’ own training, that these biases are knowable through honest and repeated reflection supported by validated tools, and that naming them is the beginning of the work rather than the end of it.

Section 3: Bias, Power Differentials, and the Patient

Bias does not operate in a vacuum. It operates within a structurally unequal relationship. In almost every clinical encounter, the clinician holds more power than the patient: more specialized knowledge, control over access to tests, referrals, medications, and documentation, the authority to define what counts as a legitimate concern, and the social standing conferred by a professional role. The patient, by contrast, is often unwell, anxious, undressed, in pain, or afraid, and is dependent on the clinician’s goodwill and judgment. This asymmetry is the power differential, the amplifier that turns a clinician’s private associations into consequences for a real person (Campbell, 2025).

The amplification works in several ways. First, because the clinician controls the interpretation of the encounter, a biased expectation can quietly become the official account. If an implicit association leads a clinician to expect that a particular patient is exaggerating symptoms, the clinician may document the visit in those terms, and that documentation then follows the patient through the system, shaping how the next clinician approaches them. Second, the power differential makes it costly for patients to push back. A patient who senses that they are not being believed may hesitate to insist, precisely because they depend on the clinician and fear being labeled difficult, which can further reduce the information the clinician receives and confirm the original misjudgment. Third, the differential is steeper for patients who already occupy a marginalized social position, so that a Black patient, a patient with limited English proficiency, a patient with a disability, or a patient with a low income may face a compounded gap in power that makes the effects of bias harder to resist (Njoku et al., 2023).

It is useful to trace how a small interpersonal moment can cascade into a clinical outcome, because the chain is what makes the power differential a safety issue rather than merely a matter of courtesy. Consider a patient whose report of severe pain or unusual symptoms is met with a subtly skeptical response shaped by an implicit association. The immediate effect is that the symptom is investigated less thoroughly. The patient, sensing skepticism and aware of the cost of being labeled difficult, may soften or withdraw the complaint, thereby removing the very information that might have prompted action. The encounter is then documented in language that reflects the original skepticism, and that documentation primes the next clinician to view the patient the same way. The patient, having learned that raising concerns is unproductive, discloses less at the next visit, attends less reliably, and waits longer before seeking help when something is genuinely wrong. In the perinatal period, where the difference between a good outcome and a catastrophe can hinge on whether a warning sign is acted on early, this cascade is not abstract. It is a plausible route from an unexamined association to a preventable harm, and it runs entirely through the power differential (Campbell, 2025; Josiah et al., 2023).

The maternal health literature describes precisely these effects. Implicit bias among clinicians has been linked to differences in communication, in the patient’s experience of care, in treatment decisions, and ultimately in outcomes, and perceived discrimination is repeatedly associated with erosion of the trust that childbearing patients place in their care teams (Josiah et al., 2023; Montalmant & Ettinger, 2024). Studies that ask patients directly find the same pattern from the other side of the encounter: Black and Latino patients have reported lower ratings of provider communication, trust in the provider, patient-centeredness, collaboration in decision-making, and the clinician’s contextual knowledge of them as a person (Blair et al., 2013). Trust is not a sentimental concern in this setting; it is functionally load-bearing. A patient who trusts the team tells the team things, returns to the team, and follows through with the team. A patient whose trust has been damaged, often by an accumulation of small dismissals rather than a single dramatic insult, may do none of these, and the resulting gaps in information and engagement are themselves risks. Because trust is built and broken across many encounters with many professionals, it is inherently a team property, which is part of why the response has to be a team response.

A particularly common channel through which bias reaches patients is the microaggression, a term for the everyday slights, dismissals, and subtle verbal or nonverbal behaviors that communicate a hostile, demeaning, or diminishing message to members of marginalized groups, often without the speaker’s awareness or intent (Sue et al., 2007). If implicit biases are the unconscious associations, microaggressions are among the behaviors that flow from them. In a clinical setting, they take recognizable forms: a comment that presumes a patient’s family structure, a term of endearment used in place of a name in a way that infantilizes, an expression of surprise at a patient’s competence, or a documentation choice that subtly casts doubt on a patient’s account. Language is central here because subtle word choices can carry biased assumptions and because the effects of biased language extend beyond a single bruised feeling, shaping health outcomes and reinforcing the belief systems behind discriminatory practices (American Medical Association, 2021). Nonverbal behavior matters as well, since bias can register in reduced eye contact, greater physical distance, or a colder tone that the patient perceives even when nothing overt is said. For the interprofessional team, the practical point is that respectful, person-centered language and attentive nonverbal communication are not merely courtesies but are themselves part of safe care, because they protect the trust on which a patient’s willingness to disclose depends.

The differential is also not uniform across patients, and the concept of intersectionality helps explain why. A patient may occupy several marginalized positions at once, for example, as a Black woman with a low income and limited English proficiency, and the disadvantages do not simply add; they interact, producing a steeper and more complex power gap than any single characteristic would predict (Njoku et al., 2023). A clinician who is attentive to race but not to language, or to disability but not to class, may still leave large blind spots. The practical implication is not that clinicians must catalog every dimension of a patient’s identity, which is impossible in the moment, but that they should hold their confident first impressions loosely, especially for patients whose social position differs most from their own, and lean on the structures and the team that the rest of this course describes.

The interprofessional lens makes the power differential more visible because different team members sit at different points in the hierarchy and see different parts of the patient’s experience. A patient may feel unable to question a physician but may speak more freely with a physical therapist during a longer hands-on session, with an occupational therapist working in the patient’s own environment, or with a behavioral health clinician whose role is explicitly to listen. These professionals often function as the team’s early warning system, hearing concerns that the patient did not feel safe raising elsewhere. Audiologists and speech-language pathologists, who frequently have repeated contact with families during newborn screening and developmental follow-up, occupy a similar position of trust. The value of this distributed vantage point is lost, however, if the team lacks the communication channels and the shared sense of permission to escalate what these members hear. A concern that a patient confides to the one clinician she trusts is worth little if that clinician has no reliable way to convey it to the people who can act, or no confidence that doing so is welcome. Recognizing the power differential, therefore, points directly to a teamwork solution: structures that flatten the hierarchy enough for patient concerns to travel, regardless of which team member first receives them, and a culture in which raising another professional’s possible blind spot is treated as good care rather than as an affront.

It is worth dwelling on trust as a clinical resource because it is easy to file under bedside manner and thereby underestimate it. In the perinatal period, the patient is often the first, and sometimes the only, person who can detect that something is wrong in her own body, and the system’s ability to act on that early signal depends entirely on whether she reports it and is believed. Trust is what makes the reporting happen. A patient who trusts her care team will mention the headache, the swelling, the strange breathlessness, the dark mood, and will do so early, when intervention is easiest; a patient whose trust has been worn away by accumulated small dismissals may say nothing until a crisis forces the issue, by which point the window for easy intervention may have closed. The maternal health literature links perceived discrimination to this erosion of trust and treats the resulting disengagement as a contributor to worse outcomes rather than as a mere matter of patient satisfaction (Josiah et al., 2023; Montalmant & Ettinger, 2024). Because trust is built and spent across many encounters with many different professionals, no single clinician owns it, and no single clinician can repair it alone, which is one more reason that protecting it is a shared, interprofessional responsibility rather than an individual courtesy.

A final point concerns the patient’s own account of being treated unfairly. Patients are often accurate observers of how they are treated, and a patient’s report of feeling dismissed or disrespected is clinical information, not a complaint to be managed away (Campbell, 2025). Treating such reports as data and responding to them with curiosity rather than defensiveness is one of the most direct ways an individual clinician can reduce the harm that flows from the power differential. It is also a behavior that any member of the team can model, regardless of discipline or seniority, making it one of the few high-value responses that do not require a system change to begin.

Section 4: Structural Racism: What It Is, How It Forms, and Its Impact on Maternal Health 

The bias discussed so far lives inside individuals and the relationships they form. Structural racism is different in kind. It refers to the way that laws, institutional policies, established practices, and cultural norms work together, often without any individual intending harm, to produce and maintain disadvantage for racially and ethnically minoritized groups (Sonderlund et al., 2022). The defining feature of structural racism is that it does not require a biased person in the room. It is built into the systems themselves, so that ordinary institutional functioning automatically reproduces inequity. For this reason, structural racism is increasingly described in the health sciences as a fundamental, upstream cause of health inequities rather than as one factor among many (Sonderlund et al., 2022; Njoku et al., 2023).

How does a structure like this form? It accumulates historically. Practices established in one era, such as residential segregation, unequal access to education and employment, discriminatory lending, and concentrated policing and incarceration, become embedded in the geography and institutions of a society and continue to shape opportunity long after the original policies are formally ended (Sonderlund et al., 2022). One useful way to operationalize the concept for research is to trace specific structural domains and the pathways by which they affect health. For example, scholars have examined how the spatial and racialized clustering of incarceration, itself a product of structural racism, is associated with adverse birth outcomes in the surrounding communities, illustrating how a structure seemingly remote from the delivery room can reach into pregnancy and birth (Sonderlund et al., 2022). The general lesson is that structural racism operates through many intermediate channels, including where people can afford to live, the quality of the hospitals accessible to them, the chronic stress of navigating discrimination, and the resources their neighborhoods do or do not contain.

In maternal health specifically, several pathways are well described, and it helps to walk through them, because each suggests a different point of intervention. One is differential access to high-quality care. Because of residential and economic segregation, Black patients in the United States are disproportionately likely to give birth in a concentrated set of hospitals, and care quality across such facilities is, on average, lower on multiple measures, so that two patients with similar needs can receive systematically different care depending on where structural forces have routed them (Montalmant & Ettinger, 2024). This is a clear example of how a structure produces a disparity without any individual at the bedside intending it: the segregation that determines neighborhood, the economics that determine which hospital serves that neighborhood, and the resourcing that determines that hospital’s quality are all upstream of the delivery room, yet they shape what happens in it.

A second pathway is the cumulative physiological toll of living with chronic stress and discrimination over the life course, sometimes described through a weathering framework, in which the sustained wear of stress contributes to earlier onset and greater severity of the chronic conditions, such as hypertension and cardiovascular disease, that drive maternal risk (Njoku et al., 2023). The idea of weathering is important because it dissolves false comfort. It is tempting to assume that a patient who is educated, insured, and financially secure has escaped the effects of racism, but the weathering framework predicts, and the data confirm, that the bodily costs of navigating a discriminatory society accumulate regardless of achievement. This is one reason the Black and White disparity in maternal mortality persists, and in some analyses widens, across higher levels of education and income, with Black women who hold a college degree experiencing worse maternal outcomes than White women with far less education (Kaiser Family Foundation, 2025). If the disparity were simply a matter of poverty or schooling, it would close as those improve. It does not, which points to racism rather than race as the operative force (Njoku et al., 2023).

A third pathway connects structural racism back to the interpersonal bias of earlier sections. Structural and interpersonal racism are not separate problems but two expressions of the same system, and they reinforce each other. Structures determine who ends up in front of which clinician, under what time pressures, and with what prior documentation, and the clinician’s implicit biases then operate within those structurally shaped encounters (Montalmant & Ettinger, 2024). A patient routed by segregation to an under-resourced, overstretched facility meets clinicians who are more rushed, which, as Section 1 noted, is exactly the condition under which automatic associations exert the most influence. The structural and the interpersonal thus compound one another, and an account that addresses only one will leave the other in place. A comprehensive understanding of maternal health disparities, therefore, has to hold both levels at once. Addressing only individual bias while leaving the structures intact will leave most of the problem in place; addressing only structures while ignoring the daily encounters in which patients are believed or disbelieved will miss the mechanism by which much harm is delivered.

The history matters because it explains why the structures are so durable. Researchers operationalizing structural racism for empirical study stress that present-day inequities are the continuation of arrangements built over generations, and that structures established in one era persist through the institutions and geography they shaped long after the original policy is formally repealed (Sonderlund et al., 2022). The illustrative case of the spatial and racialized clustering of incarceration is instructive: incarceration patterns, themselves a product of structural racism, are associated with adverse birth outcomes in the surrounding communities, showing how a structure that has nothing obviously to do with pregnancy reaches into birth through the stress, instability, economic loss, and disrupted social ties it imposes on whole neighborhoods (Sonderlund et al., 2022). The general lesson for the team is that the causes of a disparity visible in the delivery room frequently lie far outside it, in domains, housing, criminal justice, education, and employment that no clinician controls but that together determine the health a patient brings to pregnancy.

A further structural pathway operates through the simple geography of where care is available. Access to maternity services is not evenly distributed, and communities that have been disinvested through the same historical processes of segregation and economic exclusion are also those most likely to face closures of obstetric units, shortages of perinatal providers, and long travel distances to the nearest facility capable of managing a complication (Montalmant & Ettinger, 2024). A patient who must travel far for care, or who has no nearby provider she trusts, is more likely to enter prenatal care late, to attend fewer visits, and to reach a higher level of care only after a complication has advanced. These access barriers are commonly described as social determinants of health, but it is important to see that they are not random misfortunes; they are the predictable products of the structural arrangements described in this section, which is why they fall along the same racial and economic lines as the outcomes they help to produce. For the interprofessional team, this pathway is a reminder that a patient’s pattern of engagement with care, how early she came, how reliably she attends, how quickly she seeks help, reflects the structure of access around her at least as much as it reflects any choice of her own, and that interpreting missed appointments or late presentation as a personal failing repeats the very error this course is meant to correct.

It is worth stating plainly what this section does and does not claim. It does not claim that any particular clinician is racist, nor that race is a biological cause of poor outcomes. The claim, grounded in the literature, is that a system built over generations distributes risk unequally by race, that this system is a major driver of the maternal health disparities documented in the next section, and that it continues to function through ordinary institutional practice unless it is deliberately changed (Sonderlund et al., 2022; Njoku et al., 2023). For the interprofessional team, the importance of naming structure is that it widens the field of possible action beyond the individual encounter, toward the policies, referral patterns, hiring, data practices, and institutional habits that the team and its organization can influence. It also guards against a demoralizing misreading of the earlier sections. If bias were purely a matter of individual minds, the persistence of disparities despite decades of good intentions would be baffling and discouraging. Once the structure is in view, the persistence makes sense, and so does the strategy: change the systems, not only the minds.

Section 5: Maternal Morbidity and Mortality: Risk Factors and Patterns Across Populations

To act on maternal health disparities, the team needs a clear picture of the outcomes themselves. Two related terms anchor this section. Maternal mortality refers to the death of a person while pregnant or within a defined period after the end of pregnancy from causes related to or aggravated by the pregnancy or its management. Severe maternal morbidity refers to unexpected outcomes of labor and delivery that result in significant short-term or long-term consequences to a person’s health, a broader category that includes the many patients who survive a life-threatening event. Morbidity is far more common than mortality, and the two share many of the same risk factors and the same disparities, so that mortality, though rarer, serves as a visible index of a much larger burden of harm.

The clinical risk factors for maternal morbidity and mortality are reasonably well established and will be familiar to many on the team. They include cardiovascular conditions and hypertensive disorders of pregnancy, such as preeclampsia, hemorrhage, infection, venous thromboembolism, and complications of chronic conditions, such as diabetes and obesity, as well as mental health conditions and substance use disorders that contribute substantially to deaths in the year after birth (Njoku et al., 2023). Older maternal age raises risk, and access-related factors, including late entry into prenatal care or no prenatal care, lack of insurance, and limited access to facilities, compound clinical risk (Kaiser Family Foundation, 2025). Several features of these risk factors are worth emphasizing for an interprofessional audience. Many of the conditions are chronic and predate the pregnancy, which means the window for prevention opens long before conception and stays open well after delivery. Many of the deaths occur not during the dramatic hours of labor but in the weeks and months that follow. And the mental health and substance use contributions place behavioral health clinicians squarely among the disciplines whose work bears directly on maternal survival, not at the margins of it.

It is important to connect these risk factors back to the preceding sections rather than to read them as a list of individual patient failings. The chronic conditions that drive maternal risk are themselves unequally distributed by the structural forces of Section 4, and the weathering framework predicts their earlier onset among populations exposed to sustained discrimination (Njoku et al., 2023). The access-related factors are likewise structural rather than personal: whether a patient enters prenatal care early depends on insurance, transportation, work flexibility, the availability of nearby providers, and prior experiences of being treated with respect, far more than on individual motivation. And whether a developing complication is caught in time depends on the interpersonal dynamics of Section 3, on whether the patient’s early reports are believed and acted on. The risk factors, in other words, are where the structural and interpersonal forces described earlier become concrete clinical events.

The way these forces show up in maternity care has been documented directly. In obstetric anesthesia, for example, Black women have been found more likely than White women to receive general anesthesia for cesarean delivery, which carries greater risk than neuraxial anesthesia, and more likely to receive no analgesia for vaginal delivery (Tangel et al., 2020). This is exactly the kind of differential that the earlier sections predict: not a dramatic act of overt discrimination, but a pattern of treatment decisions that diverges by race in ways that accumulate into disparate risk. The same pattern appears in the management of pain more broadly, where Black and Hispanic patients have been shown to receive less effective pain treatment across a range of conditions, a disparity rooted partly in the historical and durable misconceptions about pain described in Section 2 (Aronowitz et al., 2020). For the perinatal team, these findings are not distant statistics but a description of the specific clinical decisions, about anesthesia, analgesia, and the seriousness with which pain is treated, through which bias becomes a measurable difference in the care a childbearing patient receives.

The timing data make this concrete and have direct implications for the team. Among pregnancy-related deaths, roughly one in five occur during pregnancy, nearly a quarter occur during labor or in the first week after birth, and more than half occur between one week and one year postpartum (Kaiser Family Foundation, 2025). The postpartum year, in other words, is not an afterthought but the period in which the majority of these deaths happen, which is precisely the period when physical therapists, occupational therapists, behavioral health clinicians, and pediatric-facing audiologists and speech-language pathologists are often the professionals a family sees most. A patient who has been discharged from obstetric care may still be in active contact with these disciplines, which positions them to notice the warning signs, severe headache, shortness of breath, chest pain, heavy bleeding, signs of severe mood disturbance, that can herald a late and preventable death. Equally important, the great majority of these deaths are considered preventable. Estimates indicate that more than eight in ten pregnancy-related deaths could be prevented (Kaiser Family Foundation, 2025). Preventability is the hopeful core of this material: these are not inevitable tragedies but outcomes that better systems, communication, and follow-up can avert, meaning the team’s vigilance is not a mere formality but a determinant of survival.

It is worth being concrete about what preventability means, because the abstract statistic can obscure the practical opportunity. When review committees judge a maternal death preventable, they identify points at which a different action could have changed the outcome, and those points are distributed across the system rather than concentrated in a single dramatic moment. They include missed or delayed recognition of warning signs, gaps in communication and coordination among clinicians, failures to escalate care in a timely manner, and breakdowns in follow-up after discharge, alongside patient and community factors and the access barriers discussed elsewhere in this course (Kaiser Family Foundation, 2025). Most of these are precisely the failures that an attentive, well-coordinated interprofessional team is positioned to catch. A warning sign recognized during a physical therapy session and escalated promptly, a postpartum mood disturbance identified by a behavioral health clinician and acted on, a feeding or developmental visit that becomes an occasion to ask a recovering parent how she is truly doing, each of these is a potential point of prevention. Seen this way, the preventability finding is not a distant policy abstraction but a description of the everyday clinical opportunities that the team already encounters, and a strong argument that improving how the team recognizes, communicates, and escalates is among the most direct contributions any discipline can make to maternal survival.

The patterns across populations are stark and the empirical heart of this course. In 2023, the overall United States maternal mortality rate was 18.6 deaths per 100,000 live births, a decline from 22.3 in 2022, with 669 maternal deaths recorded in 2023 compared with 817 in 2022 (Hoyert, 2025). That overall improvement, however, masks a persistent and severe racial disparity. In 2023, the maternal mortality rate for Black women was 50.3 per 100,000 live births, while the rates for White, Hispanic, and Asian women were 14.5, 12.4, and 10.7 per 100,000, respectively (Hoyert, 2025). The Black rate was more than three times the White rate and more than four and a half times the lowest group rate. While rates declined significantly for White and Hispanic women between 2022 and 2023, the rate for Black women did not improve and remained the highest by a wide margin (Hoyert, 2025). It is worth pausing on what these numbers represent. A rate of 50.3 per 100,000 is not an abstraction; it means that the everyday experience of pregnancy and birth carries a categorically different level of danger for Black women in the United States than for their White, Hispanic, and Asian counterparts, and that this has remained true even as the overall picture improved.

American Indian and Alaska Native populations require specific attention, both because the relevant learning outcome names them and because the standard reporting can render them invisible. National vital statistics typically report stable rates only for the largest race and Hispanic-origin groups, and for 2023, the data were insufficient to publish a reliable maternal mortality rate for American Indian and Alaska Native and for Native Hawaiian and Other Pacific Islander populations (Kaiser Family Foundation, 2025). This statistical suppression is itself a manifestation of how systems can obscure the populations at highest risk, since small population counts lead to fewer cells being detected, and the groups most affected become the hardest to see in the headline figures. Earlier data make the stakes clear: in 2021, American Indian and Alaska Native and Native Hawaiian and Other Pacific Islander people had pregnancy-related mortality rates of 118.7 and 111.7 per 100,000, respectively, the highest of any groups (Kaiser Family Foundation, 2025). Any honest account of maternal mortality across the five populations named in this course must therefore include the caveat that the groups facing some of the gravest risk are also the ones most often missing from the published rates, and that the absence of a number is not the absence of a problem.

It also bears emphasizing that mortality, however grave, is the narrow tip of a far larger burden. For every maternal death, many more patients survive a severe maternal morbidity event, a near miss in which hemorrhage, eclampsia, sepsis, cardiac failure, or another life-threatening complication is survived but often at the cost of lasting physical and psychological harm. These survivors carry the consequences into the postpartum year and beyond, where they intersect directly with the work of the rehabilitation and behavioral health professions: the patient recovering from an emergency hysterectomy, the patient managing the aftermath of a stroke or cardiac event, the patient whose traumatic birth has left both a physical injury and a mental health sequela. Severe maternal morbidity follows the same racial gradient as mortality, so that the populations dying at higher rates are also those surviving complications at higher rates, which means the inequity reaches a far wider group of patients than the mortality figures alone suggest (Njoku et al., 2023; Montalmant & Ettinger, 2024). For an interprofessional team, this is a reminder that addressing disparities is not only about preventing the rare death but about the much more common experience of harm that falls short of death and shapes a family’s health for years.

Two further facts about the disparity deserve emphasis because they shape how the team should think about causes. First, as noted in Section 4, the Black-White gap persists across education and income levels and is not explained by socioeconomic status, which directs attention to racism rather than individual patient characteristics (Kaiser Family Foundation, 2025; Njoku et al., 2023). This finding is worth repeating because it is the single most effective counter to the common but mistaken assumption that the disparity is really about class. Second, the persistence of the disparity in a period when overall rates improved suggests that whatever drove the general improvement did not reach Black patients equally, a pattern consistent with structurally unequal access to the gains. For the interprofessional team, the central message of this section is that maternal mortality is racially patterned, largely preventable, and concentrated in a postpartum window during which many team members are actively involved, which makes the team’s vigilance and coordination directly relevant to whether a patient lives.

Section 6: Infant Mortality and Its Ties to Maternal Health 

Maternal and infant health are bound together, biologically and socially, and the disparities in one are mirrored in the other. Infant mortality is defined as the death of an infant before the first birthday, and it is widely used as an indicator of the underlying health of mothers, the quality of perinatal care, and the social conditions in which families live (Ely & Driscoll, 2025). When a population’s mothers are sicker, less well cared for, and more stressed before and during pregnancy, its infants die at higher rates, which is why infant mortality cannot be understood apart from maternal health.

The national figures provide the baseline. In 2023, the United States infant mortality rate was 5.61 deaths per 1,000 live births, essentially unchanged from 2022, with 20,162 infant deaths recorded, a 2 percent decrease from the prior year (Ely & Driscoll, 2025). The leading causes of infant death are closely tied to the course of pregnancy: congenital malformations, disorders related to preterm birth and low birth weight, sudden infant death syndrome, injuries, and maternal complications of pregnancy (Kaiser Family Foundation, 2025). Several of these causes, particularly those stemming from preterm birth and low birth weight, are direct downstream consequences of maternal health and the conditions of pregnancy, which is the mechanical link between the two outcomes. An infant born too early or too small because of an inadequately managed maternal condition, a stressful pregnancy, or barriers to timely care begins life at a disadvantage that the best neonatal care cannot always overcome.

The racial patterning of infant mortality parallels the maternal data. Infants born to Black mothers die at more than twice the rate of infants born to White mothers, with Black infant mortality reported at roughly 10.9 per 1,000 live births compared with about 4.5 for White infants and 3.4 for Asian infants (Ely & Driscoll, 2025). American Indian and Alaska Native infants also experience elevated mortality relative to White and Asian infants. The leading contributors to the Black and White gap are the higher rates of preterm birth and low birth weight among Black infants, which again routes the explanation back through maternal health and the structural and interpersonal forces that shape it (Kaiser Family Foundation, 2025). The same disparities, the same upstream causes, and the same persistence across socioeconomic lines that characterize maternal mortality reappear in infant mortality data, providing strong evidence that the two are manifestations of a single underlying problem rather than two separate ones.

For the interprofessional team, this connection is not abstract. The infants who survive complicated pregnancies and difficult births are precisely the population that occupational therapists, physical therapists, speech-language pathologists, and audiologists follow most closely. A preterm infant may need feeding support from a speech-language pathologist, developmental and motor support from occupational and physical therapists, hearing surveillance from an audiologist, and respiratory support managed by a respiratory therapist while the parent navigates the physical recovery and the mental health consequences of a high-risk pregnancy and a fragile newborn, often with behavioral health involvement. These professionals therefore meet the downstream effects of maternal health disparities every day, frequently without naming them as such. Understanding that an infant’s developmental risk and a parent’s distress can both trace back to the same structural and interpersonal forces gives the team a more accurate picture of the family in front of them and a stronger rationale for coordinated, respectful, and vigilant care. It also reframes the team’s work as part of the prevention story: supporting maternal recovery, catching warning signs early, and sustaining a family’s trust in the care system all contribute, however indirectly, to better outcomes for the next pregnancy and the next generation.

The preterm birth pathway deserves a closer look because it is the mechanical hinge connecting maternal health to infant survival and because it carries the same disparity. Preterm birth and low birth weight are among the leading contributors to infant death, and they are more common among Black infants, which accounts for much of the Black and White gap in infant mortality (Kaiser Family Foundation, 2025). The forces that drive preterm birth are not separate from the forces described in earlier sections. The chronic stress captured by the weathering framework, the differential access to high-quality prenatal care produced by structural segregation, and the interpersonal dynamics that determine whether an emerging complication is caught and treated all feed into whether a pregnancy reaches term. An infant born too early because a maternal condition went unrecognized or untreated enters a neonatal course that the most skilled team can only partly rescue. Understanding this chain helps every discipline see that the infant outcomes they manage downstream were partly written upstream, in the quality and equity of the care the mother received, and that improving maternal care is, in a direct sense, infant care as well.

There is also a reciprocal direction to the maternal and infant relationship that matters for the postpartum team. A medically fragile newborn intensifies the stress, sleep disruption, and emotional strain on a recovering parent, raising the risk of perinatal mood and anxiety disorders at exactly the time when the parent is also managing their own physical recovery and the infant’s complex needs. Behavioral health clinicians supporting these parents, and the rehabilitation professionals helping both parent and infant regain function, are therefore working on two interlocking recoveries at once. Recognizing the dyad as a single unit of care, rather than treating mother and infant as separate cases, is consistent with the interprofessional emphasis on coordinated, whole-person care and positions the team to support the family in ways that fragmented, discipline-by-discipline attention cannot.

It is also worth stepping back to see why infant mortality carries such weight as a measure. Because an infant’s first year of life is so sensitive to the health of the mother, the quality of perinatal care, and the social conditions surrounding the family, the infant mortality rate is widely treated as a barometer of the underlying well-being of a whole population, not merely as a count of individual losses (Ely & Driscoll, 2025). When that barometer shows a rate for one group more than double the rate for another, and when the gap traces back through preterm birth and low birth weight to the same maternal health and structural forces examined throughout this course, the disparity is best read as a signal that the conditions supporting healthy pregnancy and infancy are themselves unequally distributed. For the interprofessional team, this reinforces a theme that runs through the entire course: the outcomes that appear at the very end of the causal chain, an infant lost, a mother dead, a complication survived with lasting harm, are produced by forces that operate long before and far upstream, many of which the team’s everyday practice can influence. Improving the equity of maternal care is therefore not a separate project from improving infant survival; it is, in large part, the same project viewed from a different point in the lifespan.

Section 7: The Interprofessional Team's Role in Reducing Bias and Structural Racism 

The preceding sections describe a problem with two levels, the interpersonal and the structural, and the response has to operate at both. This section turns to what the interprofessional team can actually do, with attention to what the evidence supports and what it does not.

Begin with a note of humility about training. Implicit bias training has become widespread and is now legally required for healthcare professionals in several states (Shah & Bohlen, 2023). Yet a systematic review of implicit bias training for healthcare providers and trainees found that such training is frequently characterized by methodological weaknesses and translational gaps, often diverging from the underlying science and lacking strong evidence of internal, face, and external validity, which means a single training module cannot be assumed to change behavior on its own (Hagiwara et al., 2024). This finding should not be read as a reason to abandon education, which builds the shared understanding this very course aims to provide, but rather as a reason to embed education within a larger system of change and to be skeptical of any claim that a single workshop has fixed the problem. The honest message to a team is that awareness is a starting point and that durable change requires ongoing reflection and structural support (Campbell, 2025; Hagiwara et al., 2024).

At the level of the individual encounter, several evidence-informed strategies can reduce the influence of automatic associations. Honest self-assessment is the starting point, and a widely used entry point is a confidential implicit-association measure, such as those hosted by Project Implicit, which can prompt reflection by making a clinician’s automatic associations visible, provided the result is treated as a conversation starter rather than a verdict (Kirwan Institute, 2013). Counter-stereotypic imaging and the deliberate practice of individuating, that is, focusing on the specific person rather than the group category, can weaken the grip of stereotypes, and perspective-taking and structured reflection can increase a clinician’s self-awareness and empathy, with simulation-based and reflective approaches showing some of the more consistent positive effects in the literature (Campbell, 2025). Practices that reduce cognitive load and stress, including mindfulness and emotional regulation techniques, can help because bias exerts the most influence precisely when a clinician is rushed, tired, and overwhelmed, which is the ordinary condition of much clinical work (Campbell, 2025). Underpinning all of these is the disposition of cultural humility, defined as the ability to maintain an other-oriented stance that remains open to the aspects of cultural identity most important to the patient rather than assuming expertise about the patient’s experience (Hook et al., 2013). None of these is a cure, and measured effects on implicit-association scores tend to be modest and may fade, which is why they work best as habits sustained over time rather than as one-time exercises (Campbell, 2025).

Closely related is the team’s and the organization’s capacity for cultural and linguistic competence. Cultural competence has been defined as a set of congruent behaviors, attitudes, and policies that come together in a system or among professionals to enable effective work in cross-cultural situations (Cross et al., 1989), while linguistic competence is the capacity of an organization and its staff to convey information in a way that is readily understood by patients of limited English proficiency, low literacy, or sensory disability (National Center for Cultural Competence, n.d.). The stakes are concrete: without it, encounters produce incomplete or inaccurate histories, misunderstandings of diagnoses and treatment, problems with medication and informed consent, and avoidable repeat visits. A practical, high-yield example is the use of trained, qualified medical interpreters rather than family members or friends, with attention to difficult-to-translate terms and to the physical arrangement of the encounter. For a perinatal team serving diverse families, including the audiologists and speech-language pathologists whose work centers on communication itself, building cultural and linguistic competence into routine practice is one of the more tangible ways to prevent bias and miscommunication from reaching patients.

The more powerful levers are at the team and system levels, where the interprofessional framing pays off. Standardizing assessment and decision processes, for example, using consistent protocols for evaluating and escalating warning signs such as postpartum pain, bleeding, or mood changes, reduces the room for unexamined judgment to determine who is taken seriously. Validated instruments allow a team or organization to measure awareness and mitigation of bias and to track whether interventions are actually changing practice rather than assuming they are (Bower et al., 2023). Building communication channels that allow concerns to travel across the hierarchy means that what a physical therapist or occupational therapist hears during a long session, or what a behavioral health clinician learns about a patient’s eroding trust, can reach the people who can act on it. Treating patient reports of disrespect or dismissal as safety data and reviewing adverse outcomes with an explicit eye to whether bias or unequal access played a role turns individual events into system learning. Each of these maps onto the interprofessional competency domains: shared values and ethics that center equity; clear roles and responsibilities so that no warning sign is anyone’s blind spot; communication that crosses disciplinary lines; and genuine teamwork that distributes the work of vigilance.

First Domain: Values and Ethics for Interprofessional Practice

It is worth taking each of those four domains in turn because they give the team a practical structure for organizing its response and convert a broad commitment to equity into specific, assignable behaviors. The first domain, values and ethics for interprofessional practice, asks the team to place the patient’s interest and dignity at the center of its shared work and to treat equity as a professional obligation rather than an optional virtue. In concrete terms, this means the team agrees that a patient’s report of pain or distress is to be believed and investigated regardless of the patient’s race, language, body size, or insurance status, and that respectful communication is held as a standard of care rather than a matter of individual temperament. When equity is named as a shared value, an individual clinician who slows down to take a dismissed concern seriously is acting on team policy rather than swimming against the current, and a clinician who treats a patient curtly can be understood to have departed from an agreed standard rather than merely having an off day.

Second Domain: Roles and Responsibilities

The second domain, roles and responsibilities, asks each profession to understand both its own contribution and those of the others well enough that important observations do not fall through the cracks between disciplines. In the perinatal context, this means that the physical therapist knows that the postpartum pain she is hearing about could signal a complication that belongs to the obstetric team, that the speech-language pathologist understands that a parent’s flat affect during a feeding session may be relevant to the behavioral health clinician, and that everyone knows who is responsible for escalating a warning sign and how. Role clarity is a safeguard against bias because much of the harm described in this course occurs in the spaces between professionals, where each assumes someone else has noticed and acted. A team that has mapped its roles explicitly leaves fewer such spaces.

Third Domain: Interprofessional Communication

The third domain, interprofessional communication, asks the team to communicate in a manner that is responsive, respectful, and sufficiently structured to reliably carry concerns across the hierarchy. The relevance to bias is direct, because the distributed vantage point described earlier, in which the patient confides in the clinician she trusts most, is useless if that clinician has no dependable way to convey what she heard to the people who can act, or no confidence that doing so is welcome. Structured handoffs, shared documentation that travels with the patient, and an explicit norm that raising a colleague’s possible blind spot is an act of good care rather than an accusation all serve this domain. Communication is also where trust is protected or damaged, so the team’s communication habits with the patient, not only among its members, fall under this domain.

Fourth Domain: Teams and Teamwork

The fourth domain, teams and teamwork, asks the team to apply the values, the role clarity, and the communication into a coordinated practice that performs better than the sum of its individuals. This is the domain in which the standardized protocols, the measurement of bias awareness, the review of adverse outcomes, and the flattening of hierarchy live, because each of these is a property of how the team works together rather than of any one member’s knowledge or goodwill. The evidence reviewed throughout this course points consistently toward this conclusion: because bias is a feature of normal cognition that no amount of individual effort fully eliminates, and because structural forces operate above the level of any single encounter, the durable protections are the ones built into the team’s shared routines (Campbell, 2025; Hagiwara et al., 2024; Bower et al., 2023).

Structural racism, by definition, is not solved at the bedside, but the team and its organization are not powerless before it. Within their sphere, teams can examine their own referral patterns and access barriers, advocate for the data practices that make high-risk populations visible rather than suppressed, support workforce diversity and culturally responsive care, and align with institutional and policy efforts aimed at the upstream causes (Montalmant & Ettinger, 2024; Sonderlund et al., 2022). The point is not that an audiologist or a physical therapist can dismantle structural racism single-handedly, but that the structures are made of countless ordinary practices, many of which a team can influence, and that naming the structural level keeps it from being treated as someone else’s problem.

Measurement

Measurement deserves a place of its own in the team’s response, because without it good intentions cannot be distinguished from good results. A team that wishes to know whether it is reducing the harm of bias has to look at data, and several kinds are available. Validated instruments can assess awareness of and mitigation of bias within a maternity care setting, providing a team with a baseline and a way to detect change over time, rather than relying on the assumption that training or a policy must have helped (Bower et al., 2023). Stratifying clinical and experience measures by race and ethnicity, for example, examining whether pain is assessed and treated equally, whether warning signs are escalated equally, and whether patients of different groups report equivalent respect and trust, can make a hidden disparity visible and turn it into an actionable target. Reviewing severe morbidity and mortality events with an explicit question about whether bias or unequal access contributed converts individual tragedies into system learning. None of these measurements is punitive in spirit; its purpose is to replace the comfortable assumption that a team is doing well with evidence about whether it actually is, and to direct effort toward the points where the data show the largest gaps. This emphasis on measurement also guards against the documented risk of mistaking a single educational intervention for a solution, since the data will make it plain whether practice has changed (Hagiwara et al., 2024).

Care Models and Programs That Have Reduced Maternal Harm

The strategies in this section are not only theoretical; they are embodied in established programs whose results have been measured. The leading national example is the Alliance for Innovation on Maternal Health (AIM), a federally funded program coordinated through the American College of Obstetricians and Gynecologists that develops and disseminates maternal patient safety bundles, which are standardized, evidence-based sets of practices aimed at the leading preventable causes of maternal death and severe morbidity, including obstetric hemorrhage, severe hypertension and preeclampsia, sepsis, and perinatal mental health and substance use conditions. As of early 2025, AIM bundles were being implemented in roughly 2,000 birthing facilities across 49 states, the District of Columbia, and Puerto Rico (Health Resources and Services Administration, 2025). Each bundle is organized around the domains of readiness, recognition, response, reporting, and respectful care, and the deliberate inclusion of respectful and equitable care places the trust and bias concerns of this course within the safety framework rather than beside it (American College of Obstetricians and Gynecologists, n.d.).

This model has a measurable track record. The California Maternal Quality Care Collaborative (CMQCC) pioneered bundle-based perinatal quality improvement, and in a peer-reviewed evaluation of 99 collaborative hospitals, patients experiencing obstetric hemorrhage showed a 20.8 percent reduction in severe maternal morbidity compared with a 1.2 percent reduction in non-participating comparison hospitals, with a larger 28.6 percent reduction in hospitals that had prior collaborative experience (Main et al., 2017). At the state level, California’s maternal mortality rate fell by roughly 65 percent between 2006 and 2016, a period when the national rate was rising, a decline that CMQCC attributes substantially to these collaborative quality-improvement efforts (California Maternal Quality Care Collaborative, n.d.).

Two features make these programs directly relevant to this course. First, the gains are produced through precisely the team and system mechanisms described above, namely standardized recognition and escalation, rehearsed emergency response, and the routine review of data, rather than through individual exhortation; the bundles have since been revised to embed respectful and equitable care, and collaboratives increasingly stratify outcomes by race and ethnicity so that improvements reach the patients at highest risk (American College of Obstetricians and Gynecologists, n.d.; Montalmant & Ettinger, 2024). Second, they give the interprofessional team a concrete picture of what success looks like: a patient is less likely to die or to suffer severe harm when every discipline recognizes the warning signs, the team has practiced its response, and the data are watched to see who is being left behind. For the disciplines represented in this activity, these programs are the structural counterpart to the individual habits of listening and believing, and they show that the layered response this course recommends is not aspirational but already at work.

Finally, every team member's role includes the conduct of individual relationships, where evidence and ethics converge. Listening to patients, believing their reports of their own bodies, communicating respectfully, and protecting trust are not soft additions to clinical care but, in a period when most maternal deaths are preventable, and many depend on a patient’s warning being heard, are themselves safety interventions. The interprofessional team’s role in reducing the impact of implicit bias and structural racism for pregnant and postpartum patients is therefore both modest and essential: modest because no single profession or person controls the outcome, and essential because the outcome is built from exactly the encounters, hand-offs, and habits that the team controls together.

Pulling these threads together, the response the evidence supports is layered rather than singular. At the level of the individual clinician, it asks for honest, sustained self-examination and for the everyday discipline of listening to patients and believing their reports of their own bodies. At the level of the team, it asks for shared values that center on equity, clear roles so that warning signs are no one’s blind spot, communication that carries concerns reliably across the hierarchy, and coordinated routines that perform better than the sum of their members. At the level of the system, it calls for standardized processes, measurements that reveal disparities rather than hide them, and engagement with structural and access barriers that route patients to unequal care. No single layer is sufficient on its own: individual goodwill without team structure leaks; team structure without individual listening has nothing to carry; and both together still operate within structures that must be named and addressed. One way to hold these layers together is the image of a cycle that can turn in either direction: structural determinants and biased decision-making can feed a vicious cycle of diminished care and worse outcomes, while sound decision-making and supportive structures can feed a virtuous cycle of improved care and better outcomes, with the clinician and the team positioned at the point where the cycle can be redirected (Vela et al., 2022). What makes this an interprofessional rather than a single-discipline task is that each of these layers depends on contributions from every profession that touches the childbearing family, from behavioral health to audiology, and that the safety of the patient emerges from how those contributions are coordinated. The hopeful conclusion, grounded in the finding that the great majority of maternal deaths are preventable, is that this is a problem largely within the team’s power to influence, provided the team takes it up together rather than leaving it to the conscience of individuals (Campbell, 2025; Hagiwara et al., 2024; Bower et al., 2023; Kaiser Family Foundation, 2025).

Application to Team-Based Practice

The material in this course reaches each represented profession differently, and naming those connections helps every reader locate their own role. Behavioral health clinicians often hold the relationships in which a patient feels safe enough to disclose distrust, perceived discrimination, or worsening symptoms, and they treat the perinatal mood and anxiety disorders that contribute to maternal deaths in the postpartum year, which places them at the center of both the trust and the clinical-risk dimensions of this material. Physical therapists frequently spend extended, hands-on time with patients managing pelvic floor dysfunction, musculoskeletal pain, and postpartum recovery, and that time is an opportunity both to hear concerns that were not voiced elsewhere and to model the practice of believing a patient’s report of pain, a domain with a documented history of biased underestimation. Occupational therapists support feeding, infant development, and a parent’s return to daily roles, often in the patient’s own environment, where they can observe context that the clinic never sees and where the power differential may relax enough for honest exchange. Speech-language pathologists and audiologists conduct newborn feeding and hearing screenings and follow developmentally at-risk infants across repeated visits, which makes them trusted longitudinal contacts for families navigating the downstream consequences of high-risk pregnancies and positions them to notice and escalate parental concerns over time. Respiratory therapists manage the ventilation and oxygen support that medically fragile newborns rely on and assist with the maternal respiratory complications that can arise during pregnancy and the postpartum period, which places them among the clinicians most likely to encounter warning signs such as shortness of breath and to act on them quickly.

Across all of these roles, the shared behaviors are the same. Each profession makes rapid judgments under pressure that are vulnerable to implicit associations, each occupies a position in a power differential relative to the patient, each meets families who carry the effects of structural forces they did not choose, and each can either protect or undermine a patient’s trust in the care system. The interprofessional opportunity is to ensure that the distinct vantage points add up to more than their sum, so that a concern heard by one discipline reaches the whole team, and so that the values, role clarity, communication, and teamwork that reduce the harm of bias are built into how the team works rather than left to individual goodwill.

A few illustrative situations show how these principles become concrete and how the team functions as a single safeguard. Consider a postpartum patient who mentions to her physical therapist, during a session for pelvic pain several weeks after delivery, that she has also been having headaches and some shortness of breath, symptoms she has not raised with anyone else because a previous clinician seemed to brush off her concerns. The physical therapist who has absorbed this material recognizes two things at once: that these symptoms can signal a serious late postpartum complication, and that the patient’s reluctance to report them is itself a product of an eroded trust that bias can cause. The values domain tells the therapist to take the report seriously; the roles domain tells her that escalation belongs to the obstetric or emergency pathway; the communication domain gives her a reliable way to convey the concern; and teamwork ensures the handoff is received rather than lost. The same chain could begin with an occupational therapist noticing a parent’s distress during a home visit, a speech-language pathologist observing that a parent seems disengaged during a feeding session, or a behavioral health clinician learning that a patient has stopped trusting her care team. In each case, the discipline that first receives the information is not expected to manage the complication alone, but to recognize its significance and to move it into the team’s shared field of action.

These scenarios also illustrate why the individual relationship and the team structure are complementary rather than competing. The therapist’s decision to believe the patient and to respond with curiosity rather than dismissal is an individual behavior, available to any clinician without waiting for a system change, and it is exactly the behavior that keeps a patient willing to disclose. But whether that disclosure leads to timely care depends on the team structures around it, the channels, the role clarity, and the shared norms that carry the concern to the people who can act. A clinician with excellent personal habits embedded in a team that has no way to escalate her observations will still watch concerns evaporate, and a well-structured team staffed by clinicians who do not listen will have nothing worth escalating. The interprofessional response to bias, therefore, asks for both at once: the individual disposition to listen, believe, and respect, and the collective structures that turn what is heard into what is done.

Summary

This course examined implicit bias and its impact on maternal health in minority populations, building from individual psychology toward structural forces and the outcomes at stake, and it returns now to each learning outcome. It differentiated implicit bias, which operates automatically and outside awareness, from explicit bias, which is consciously held, and explained how both can shape clinical interactions even in well-intentioned clinicians (LO1). It described how stereotypes, prejudice, and “isms” form and evolve through lifespan socialization, and identified self-assessment instruments, reflective practice, and continuing education as resources for examining one’s own biases, while noting that awareness is a beginning rather than an end (LO1). It examined how bias and power differentials affect the patient and the patient-team relationship, eroding communication and trust in ways that pose safety concerns in the perinatal period (LO2). It gave examples of structural racism, described how it forms and accumulates historically, and explained its impact on maternal health through pathways such as differential access to quality care and the cumulative toll of chronic stress (LO3). It identified the major risk factors for maternal morbidity and mortality and described the patterns across populations, including a 2023 Black maternal mortality rate more than three times the White rate, the persistence of that disparity across education and income, and the elevated and often statistically suppressed rates among American Indian and Alaska Native and Native Hawaiian and Other Pacific Islander populations (LO3). Finally, it described United States infant mortality and its ties to maternal health and pregnancy-related complications, and summarized the interprofessional team’s role in reducing the impact of implicit bias and structural racism for pregnant patients, a role that is modest at the level of any one profession and essential at the level of the team’s shared encounters, hand-offs, and habits (LO4). The through-line is that most maternal deaths are preventable, that the harm is racially patterned and structurally produced, and that the perinatal team, working as a team, holds many of the levers that determine whether a patient is heard, believed, and kept safe.

References

Please see the additional handout.

This text-based course is an edited transcript of the webinar, Supporting Queer and Trans Clients in the Current Political Climate: Ethical Dilemmas and Interventions in Trying Times, presented by Giselle Levin, PsyD on October 6, 2025.

Course Overview

This course provides a comprehensive examination of the current sociopolitical landscape affecting queer and transgender clients in the United States. It explores the profound impact of anti-transgender legislation, media rhetoric, and healthcare bans on the mental health and psychosocial functioning of gender-diverse individuals. Through the lens of minority stress theory and clinical case studies, the course outlines specific ethical dilemmas mental health providers face, including issues related to detransition, "Do-It-Yourself" (DIY) hormone therapy, and documentation safety. Ultimately, it provides clinicians with actionable interventions and advocacy strategies to support client resilience and navigate these complex challenges.

Course Information

Giselle Levin, PsyD (they/she/he), is a licensed psychologist in the state of California specializing in transgender healthcare and sex therapy. Giselle completed their doctorate at Pace University in New York, NY, and trained as a postdoctoral resident in LGBT mental health at the San Francisco VA Medical Center. They currently work as a gender specialist at the University of California San Francisco - Child and Adolescent Gender Center. Giselle is a member of UCSF’s Mind the Gap consortium of gender-affirming providers for youth and is in the process of completing their AASECT sex therapy and WPATH transgender healthcare certifications.

Disclosures

• Presenter Disclosure:

  • Financial: Dr. Giselle Levin, PsyD received an honorarium for presenting this course. Giselle Levin has published articles on transgender healthcare, sex therapy, multiple minority stress, and adapting evidence-based interventions for marginalized populations.

  • Non-financial: Giselle Levin has no relevant non-financial relationships to disclose.

• Content Disclosure: This learning event does not focus exclusively on any specific product or service.

• Sponsor Disclosure: There is no external sponsor for this course.

Limitations/Risks

• Practitioners should cultivate cultural humility and cultural competence while committing to respect the diverse ethical and legal obligations associated with different regions and cultures.

• This course is geared toward mental health professionals who already possess fundamental knowledge and skills necessary to work with LGBT individuals.

• Ensure that you have adequate training prior to working with the above populations; consult or refer out as necessary.

• You are ethically required to refer out if you hold significant negative bias toward LGBT individuals.

• Reparative/conversion therapy is unethical and harmful.

Ethics Codes

Below are links to Ethics Codes for some of the major behavioral health professions. Please ensure you always refer to your own ethical code.

• AAMFT: https://www.aamft.org/Legal_Ethics/Code_of_Ethics.aspx

• ACA: https://www.counseling.org/resources/aca-code-of-ethics.pdf

• APA: https://www.apa.org/ethics/code

• NBCC: https://nbcc.org/assets/ethics/nbcccodeofethics.pdf

• NAADAC: https://www.naadac.org/code-of-ethics

• NASW: https://www.socialworkers.org/About/Ethics/Code-of-Ethics/Code-of-Ethics-English

Learning Outcomes

After this course, participants will be able to:

• Explain at least three reasons for increased mental health concerns in queer and trans clients, including substance use, depression, suicidality, anxiety, self-harm, and disordered eating.

• Analyze ethical conflicts and considerations when working with queer and trans clients, including youth and their families.

• Identify two interventions that can be used with queer and trans clients to mitigate the impact of minority stress on mental health.

Current Climate

It's Going Down in History...

The current sociopolitical environment in the United States and globally is characterized by a significant intensification of rhetoric and policy directed against transgender and gender-diverse individuals. Providers and clients alike are navigating a period that some historical records may eventually classify as a time of persecution. For example, Wikipedia currently hosts an article titled "Persecution of transgender people under the second Trump administration," highlighting the severity with which these legislative and social shifts are being documented and perceived.

The rhetoric has shifted dangerously from pathologizing transgender individuals as "mentally ill" to framing them as "actively malicious" or as "terrorists." This progression—from stigmatization to dehumanization—is a known trajectory in the persecution of marginalized groups. This dehumanization manifests in several specific ways:

• Removal of Legal Rights: There are active efforts to strip transgender individuals of legal protections and recognition.

• Purge of Trans Government Employees: Reports indicate threats to the careers of transgender individuals working within the federal government and military sectors.

• Restriction on Passports and International Travel: New policies and proposals threaten the ability of transgender people to travel freely and safely.

• Promotion of Trans Healthcare Misinformation: Major news outlets, including those traditionally viewed as progressive, have published articles that question the validity and safety of gender-affirming care, causing confusion even among supportive allies.

• Attempts to Shut Down and Intimidate Providers: Clinics providing gender-affirming care (GAC) face threats to funding and legal intimidation, leading some to close or cease services.

• Portrayal of Trans People as Social Threats: The framing of transgender individuals, particularly trans women, as threats to women and children contributes to a hostile social environment.

Passport Updates

The ability to obtain accurate identification documents is a critical component of safety and social functioning for transgender individuals. Recent executive orders and legal challenges have centered on the inclusion of "biological sex" on passports, threatening to reverse progress made in allowing gender markers that align with an individual's identity (such as "X" markers or allowing self-selection of "M" or "F").

While lower courts have blocked some discriminatory policies, allowing some individuals to successfully update their documents, the threat of reversal remains. For example, a transgender man who passes as cisgender male may have a driver's license with an "M" marker. If his passport were forced to revert to an "F" marker based on birth assignment, international travel would become dangerous. Presenting a passport with a female marker while appearing phenotypically male in countries with strict gender laws or hostile climates could lead to harassment, detainment, or violence.

Furthermore, these restrictions impact families. Parents of transgender children express profound fear regarding travel. A parent of a six-year-old transgender girl, who has socially transitioned and lived as a girl for years, may fear that traveling internationally could result in accusations of child abuse or the removal of the child from their custody if documents do not align with the child's presentation. These fears effectively trap families within the country, limiting their freedom of movement.

State-by-State Map for GAC Youth Bans

The legal landscape regarding gender-affirming care for youth is a patchwork of bans, restrictions, and protections that varies significantly by state. It is crucial for providers to understand that the bans targeting gender-affirming care often prohibit treatments that are deemed medically necessary by every major medical association in the country.

A critical ethical and legal distinction exists regarding these bans: the medications being banned for gender-affirming care are often legal and routinely prescribed for other conditions. For instance, puberty blockers (GnRH analogues) are the standard treatment for precocious puberty (puberty occurring too early). A child with precocious puberty can access these medications with standard parental consent. However, in states with bans, a transgender child seeking the exact same medication to pause puberty for gender-affirming purposes—a fully reversible intervention—is denied access. This highlights the discriminatory nature of the legislation, which targets the identity of the patient rather than the safety of the medication.

Image Caption: As of 2025, over 25 states have enacted bans on best practice medical care for transgender youth, with some states making it a felony crime to provide such care (Movement Advancement Project, 2025).

As illustrated in the map above, the legal status of care is volatile:

• Felony Crime to Provide Care: Enacted in states such as North Dakota, Oklahoma, Idaho, Alabama, South Carolina, and Florida.

• Bans to Provide Care: Enacted in over 20 states including Texas, Utah, Georgia, and North Carolina.

• Protections: States like California, New York, and Minnesota have enacted "shield laws" or remain states where care is legal.

However, legality does not guarantee access. Even in "green" states, clinics may face immense pressure to stop providing care due to funding threats or harassment.

Other GAC Updates

Beyond state laws, other systemic threats are eroding access to care:

• Surgical Centers: Many surgical centers have voluntarily stopped providing care to youth under 19, even in states where it remains legal for those under 18 with parental consent. This age limit is often a reaction to executive orders or fear of litigation rather than clinical guidelines.

• Clinic Closures: Some major medical centers have shut down their gender health programs entirely due to political pressure, effectively abandoning patients who rely on them for hormone management and mental health support.

• Funding Threats: There are ongoing threats that the Centers for Medicare & Medicaid Services (CMS) could withdraw federal funding from hospitals that provide gender-affirming care. Because most major hospitals rely on CMS funding for their general operations, this threat endangers the financial viability of entire medical institutions, forcing them to choose between financial survival and providing specialized care.

Tracking Anti-Trans Legislation

Given the rapid changes in legislation, mental health providers must stay informed about the laws in their specific jurisdiction. Reliable resources for tracking this information include:

• Erin in the Morning: An independent journalist providing an "Anti-Trans Legislative Risk Assessment Map" and frequent updates.

• ACLU: Tracks anti-LGBT bills moving through state legislatures.

• Trans Legislation Tracker: A comprehensive database of bills impacting transgender rights.

Impact on Patients

Increase in DSM-5 Symptoms & Decrease in Psychosocial Functioning

The hostile political climate has a direct and measurable impact on the mental health of queer and transgender clients. Clinicians are observing a rise in clinical symptoms and a decline in psychosocial functioning across the lifespan, from young children to older adults.

Commonly observed symptoms include:

• Depression and Anxiety: Exacerbated by chronic uncertainty and fear.

• Suicidality and Self-Harm: Rates are rising as hope for a safe future diminishes.

• Disordered Eating: Often linked to attempts to control body shape or suppress secondary sex characteristics.

• Somatic Complaints: Many children present with gastrointestinal (GI) issues, often linked to anxiety or avoiding school bathrooms due to safety concerns.

• School Refusal: Children are increasingly refusing to attend school due to bullying and lack of safe facilities.

• Social and Family Conflict: The political climate has polarized families, leading to rejection or conflict where there may previously have been tolerance.

• Decreased Job Performance: The stress of potential job loss (e.g., for military or government employees) impacts professional functioning.

Research supports these clinical observations. A study by Lee et al. (2024) found statistically significant increases in suicide attempts among transgender youth aged 13-17 in the first year after state-level anti-transgender laws were enacted. Furthermore, exposure to news about anti-transgender legislation is associated with higher levels of depression, anxiety, and physiological stress responses (Dhanani & Totton, 2023). Restar et al. (2024) also found that transgender adults living in states with hostile policy environments reported significantly higher symptoms of depression and anxiety compared to those in more protective states.

Understanding Increase in Symptoms

The correlation between the political landscape and mental health symptoms is driven by several factors:

• Reduced Access to Care: Patients fear losing access to hormones or puberty blockers. For a young person who has socially transitioned, the prospect of undergoing an endogenous puberty that contradicts their gender identity is terrifying.

• Bullying and Harassment: School environments have become increasingly hostile, with reports of physical assaults and death threats against queer students becoming more common.

• Job Instability: Transgender individuals in the military or federal sectors face the potential erasure of their careers.

• Media Exposure: Constant exposure to dehumanizing media rhetoric acts as a chronic stressor. While some clients may try to disconnect, many feel a need to monitor the news to assess threats to their safety ("knowing the hunter is out there").

• Fears of Future Discrimination: Anxiety is often future-oriented, focused on the potential for forced detransition, family separation, or the need to flee the country.

Minority Stress Theory

Minority Stress Theory provides a framework for understanding how societal stigma translates into individual mental health outcomes. It posits that marginalized groups face chronic stress distinct from the general population.

Image Caption: The relationship between external stressors and internal psychological processes leading to adverse health outcomes (Testa et al., 2015).

As defined by Testa et al. (2015), the theory divides stressors into:

• Distal Stress Factors (External): These are objective events such as discrimination, rejection, victimization, and non-affirmation of identity.

• Proximal Stress Factors (Internal): These are the internal psychological processes resulting from the distal stressors, including internalized transphobia, expectations of rejection, and concealment of identity.

These factors combine to degrade mental and physical health, leading to higher rates of suicide and chronic illness.

Multiple Minority Stress

Clients often hold multiple marginalized identities, leading to compounded stress (intersectionality). Clinicians must consider the unique experiences of:

• BIPOC Communities: particularly Black, Indigenous, and Latinx transgender individuals who face racism alongside transphobia.

• Immigrant Communities: Undocumented families may fear that seeking gender-affirming care will draw attention to their immigration status.

• Religious Minorities: Jewish and Muslim transgender individuals may face rising antisemitism or Islamophobia in addition to transphobia.

• People with Disabilities: There is a high overlap between neurodivergence (specifically autism) and gender diversity. Attacks on disability rights and healthcare access further marginalize this population.

• Veterans: Those relying on the VA for care face specific anxieties regarding federal policy changes.

Increase in Disordered Eating

Disordered eating in the transgender population is often functionally different from that in cisgender populations. It can be a mechanism to manage gender dysphoria by altering the body. For example, starvation may be used to stop menstruation or reduce breast tissue development, while other behaviors might be used to reduce muscle mass or curves.

Research indicates that gender-affirming hormone therapy (GAHT) is protective against disordered eating. When individuals can access hormones that align their physical body with their gender identity, the need to use maladaptive eating behaviors to control their body often decreases. Conversely, losing access to GAHT may precipitate a relapse into disordered eating. Additionally, logistical barriers, such as the lack of safe bathrooms, can lead to restrictive behaviors (avoiding food and water) to prevent the need to use the restroom during the school or work day.

The Dangers of Conversion Therapy

With the restriction of affirmative care, some political factions promote "conversion" or "reparative" therapy as an alternative. This practice attempts to change a person’s sexual orientation or gender identity.

Data from the 2015 U.S. Transgender Survey highlights the extreme danger of this approach. Youth exposed to conversion therapy had a 55% increase in the risk of attempting suicide compared to those who were not. The risk of running away from home also doubled. These risks were highest for those exposed to the practice at a young age (between 11 and 14) (Campbell & van der Meulen Rodgers, 2023).

Mental health professionals have an ethical mandate to "Do No Harm." Engaging in or referring clients to conversion therapy violates this fundamental ethical principle.

Ethical Dilemmas

The current political climate creates complex ethical dilemmas where legal mandates, client safety, and clinical best practices may conflict.

Can You Support Detransition?

Case Study: Jay Jay is an 80-year-old transfeminine nonbinary veteran who, after a lifetime of suppressing their identity, began estrogen therapy. They experienced great joy in developing a feminine body. However, due to economic factors, Jay lost their housing in San Francisco and had to move to a rural area in Oregon to afford a home. In this new environment, Jay perceived a high threat of transphobia and physical violence. Consequently, Jay decided to stop taking hormones and "detransition" to ensure their physical safety.

Ethical Consideration: Clinicians may struggle with supporting a client in stopping a treatment that clearly benefits their mental health. However, in this case, the detransition is driven by external safety concerns rather than an internal shift in identity. Research indicates that over 82% of individuals who detransition do so because of external factors like family rejection or societal stigma, rather than a realization that they are not transgender.

In this scenario, the clinician’s role is to respect the client's self-determination and safety needs. Supporting Jay involves validating the unfairness of the situation, helping them grieve the loss of their authentic expression, and prioritizing their physical safety and housing stability.

When Clients Choose to Go DIY

Case Study: Jasper Jasper is a 23-year-old trans man who wishes to take testosterone. However, he distrusts the medical establishment, fearing that a formal prescription could be tracked or cut off by future legislation. Instead, he obtains testosterone from an unregulated source ("DIY"). He wants to continue therapy to process the changes but refuses to see a medical provider for the hormones.

Ethical Consideration: This presents a dilemma regarding scope of competence and safety. A therapist cannot prescribe or manage medication. However, refusing to treat Jasper could alienate him from his only source of mental health support.

The recommended approach is harm reduction. Similar to working with a client who uses substances or engages in self-harm, the clinician does not condone the risky behavior but works to minimize danger. This involves:

• Acknowledging the client's valid fears of the medical system.

• Educating the client on the risks of unmonitored hormone use (e.g., polycythemia, liver strain).

• Encouraging any possible safety steps (e.g., "If you won't see a doctor for a prescription, would you consider getting blood work done at a private lab to check your levels?").

• Discussing safe injection practices.

Documentation & Ethics

With the Department of Justice and other entities issuing subpoenas for medical records of transgender patients, documentation has become a safety issue.

Key Questions for Clinicians:

• Diagnosis: Do you include a diagnosis of Gender Dysphoria (F64.0)? While necessary for insurance coverage, it can also serve as a flag in medical records. If a client is paying out of pocket or seeking therapy for unrelated issues (e.g., anxiety), is the diagnosis necessary?

• Names and Pronouns: Do you document the client's chosen name and pronouns in the official chart, or keep them in a separate "shadow" file? Documenting them validates the client but could expose them if records are seized.

• Relationship Status: How are same-sex partners documented?

Intervention: Adopt a consent-forward approach. Have transparent conversations with clients about documentation. Ask: "I want to respect your identity, but I also want to protect your privacy. Here are the risks and benefits of documenting your chosen name in the official record. What do you prefer?"

Should We Delay GAC?

Case Study: Molly Molly is a 16-year-old trans girl who has socially transitioned and is desperate to start estrogen. Her therapist and doctors agree it is medically appropriate. However, her parents, while affirming of her identity, are terrified of the political climate. They want her to wait until she is 18 or until the political situation stabilizes to ensure her safety.

Ethical Consideration: This is a conflict of values: Safety vs. Authenticity. The parents prioritize physical safety; Molly prioritizes the quality of her life and her authentic development.

Intervention: The clinician's role is to facilitate a values-based conversation. For Molly, living as a boy might feel like a fate worse than the risk of discrimination. The therapist can help the family navigate this by validating the parents' fear while highlighting that denying care also carries severe risks (e.g., suicidality, worsening dysphoria). The goal is to help the family find a consensus that respects the adolescent's developing autonomy and the reality of their dysphoria.

Can Therapists Be Political?

Historically, mental health professions encouraged neutrality. However, the current context challenges this stance.

• The Personal is Political: The DSM-5 itself is a sociopolitical document, not just a scientific one. The laws governing practice are political. Conceptions of mental health are shaped by societal values.

• Ethical Obligation: Hope and Puckett (2024) argue that mental health providers are ethically required to engage in advocacy. Silence in the face of legislation that harms clients can be complicit.

• Scope of Advocacy: Advocacy can take many forms, from voting and calling legislators to attending protests or simply creating a safe, affirming space in the therapy room.

Image Caption: Engaging in public advocacy is one form of ethical action for mental health providers (Image: G. Levin).

Recommendations

General Recommendations for Providers

1. Consultation: Do not make decisions in isolation. Consult with legal experts regarding state laws and with colleagues regarding ethical gray areas.

2. Avoid Rash Decisions: Do not preemptively strip all charts of pronouns or cease care based on rumors. Base actions on verified legal and clinical information.

3. Communication: Clearly communicate your stance on privacy and advocacy to your clients. Knowing their therapist is "on their team" is a vital intervention in itself.

4. Advocacy: Engage in advocacy appropriate to your capacity. "Be loud" where you can.

5. Self-Care: Vicarious trauma is real. Find your own sources of resilience and joy.

Building Rapport

• Explicit Allyship: Do not assume clients know you are safe. State clearly that you are committed to LGBT rights.

• Proactive Inquiry: Do not wait for the client to bring up the news. Ask: "I know there has been a lot of heavy news regarding trans rights lately. How is that impacting you?"

• Knowledge: Do not place the burden of education on the client. Stay informed about major legislative updates so the client does not have to explain basic news events to you.

Recommendations for Patients: The Crash Pad

Clinicians can use the metaphor of a "Crash Pad" with clients. If the client feels they are climbing a dangerous cliff (navigating society), they cannot control whether they fall (legislation/discrimination), but they can build a crash pad to catch them.

Components of a Crash Pad:

• Community: Connection with other trans people.

• Supportive Individuals: A trusted cousin, friend, or therapist.

• Affirming Environments: A workplace or hobby group where they are respected.

• Practices: Meditation, exercise, or art that grounds them.

• T4T Relationships: "Trans for Trans" relationships, where partners share a mutual understanding of the gendered experience, can be a profound source of safety and intimacy.

Image Caption: The "Crash Pad" intervention helps clients visualize and strengthen their support network.

Queer/Trans Joy as Resistance

While it is necessary to discuss trauma and safety, it is equally important to center Queer and Trans Joy. Encouraging clients to access joy—through community events, pride celebrations, or personal expression—is a form of resistance against a system that seeks their misery

Recommendations for Parents

Parents often ask how much they should share with their children about the political climate.

• Assess Capacity: Consider the child's age and emotional maturity.

• Assume Knowledge: Children often know more than parents realize through social media and peers.

• The "Need to Know" Approach: A parent can ask, "Do you want to know what is going on in the news, or do you want me to handle it?"

  • Example: A father asked his 12-year-old daughter this question. She replied that she just wanted to be a kid. The father agreed to carry the burden of political awareness and advocacy so she could focus on her childhood. This is a model of protective parenting.

Using a Values-Based Approach

When clients or families feel stuck, a values clarification exercise can be powerful.

Image Caption: Mapping conflicting values helps clients understand their decision-making process in complex situations.

Clinicians can help clients identify their core values (e.g., Authenticity, Safety, Family Harmony) and acknowledge that these values may currently be in conflict. There is no single "right" answer; different clients will prioritize different values (like Jay choosing safety vs. Molly choosing authenticity).

Resources

Providing clients with concrete resources is an essential intervention.

• Relocation and Logistics:

  • Keshet Move to Thrive: Offers interest-free loans for relocation.

  • Project Open Arms: Resettlement project for trans families.

  • Elevated Access: Volunteer pilots providing free transportation to states with legal healthcare access.

• Legal and Support:

  • Trans Family SOS: Guiding families through legal and medical navigation.

  • Trevor Space: Online community for LGBTQ youth.

  • Human Rights Campaign: Emergency funds and resources.

References

American Psychiatric Association. (2022). Diagnostic and statistical manual of mental disorders (5th ed., text rev.). American Psychiatric Association. https://doi.org/10.1176/appi.books.9780890425787

Campbell, T., & van der Meulen Rodgers, Y. (2023). Conversion therapy, suicidality, and running away: An analysis of transgender youth in the US. Journal of Health Economics, 89, 102750. https://doi.org/10.1016/j.jhealeco.2023.102750

Dhanani, L. Y., & Totton, R. R. (2023). Have you heard the news? The effects of exposure to news about recent transgender legislation on transgender youth and young adults. Sexuality Research and Social Policy, 20(4), 1345-1359. https://doi.org/10.1007/s13178-023-00869-7

Hope, D. A., & Puckett, J. A. (2024). Bans on evidence-based care for transgender and gender diverse people present risks for clients and dilemmas for mental health providers. Cognitive and Behavioral Practice, 31(1), 15-19. https://doi.org/10.1016/j.cbpra.2023.08.001

Lee, W. Y., Hobbs, J. N., Hobaica, S., DeChants, J. P., Price, M. N., & Nath, R. (2024). State-level anti-transgender laws increase past-year suicide attempts among transgender and non-binary young people in the USA. Nature Human Behaviour, 8(11), 2096-2106. https://doi.org/10.1038/s41562-024-01928-0

Movement Advancement Project. (2025). Healthcare laws and policies: Bans on best practice medical care for transgender youth [PDF]. Movement Advancement Project. https://www.lgbtmap.org/img/maps/citations-youth-medical-care-bans.pdf

Restar, A., Layland, E. K., Hughes, L., Dusic, E., Lucas, R., Bambilla, A. J., & Kershaw, T. (2024). Antitrans policy environment and depression and anxiety symptoms in transgender and nonbinary adults. JAMA Network Open, 7(8), e2431306. https://doi.org/10.1001/jamanetworkopen.2024.31306

Testa, R. J., Habarth, J., Peta, J., Balsam, K., & Bockting, W. (2015). Development of the Gender Minority Stress and Resilience Measure. Psychology of Sexual Orientation and Gender Diversity, 2(1), 65-77. https://doi.org/10.1037/sgd0000081

This text-based course is an edited transcript of a live webinar presented by Ryan Kirk, PsyD.

This material is for educational purposes and does not replace clinical judgment or local policy.

Risks/Limitations

• This course provides foundational training but does not certify clinicians in EMDR or specialized trauma interventions.
• Clinicians are encouraged to seek further supervised training specific to EMDR protocols and advanced telehealth competencies.
• Due to diverse client populations, cultural competence strategies discussed may require tailored adaptations in unique clinical contexts.
• Participants are advised to consult state-specific telehealth guidelines for complete compliance.

Learning Outcomes

After this course, participants will be able to:

• Identify ethical considerations, diversity, equity, and inclusion (DEI) strategies, and best practices for culturally competent telehealth services.
• Describe strategies for effectively adapting trauma interventions, EMDR, and child and play therapy techniques for telehealth settings.
• Explain methods to establish and maintain human connection and therapeutic rapport during virtual sessions.

Introduction

Telehealth has undergone a profound transformation, particularly since 2020, becoming an indispensable modality in behavioral health. This shift, largely accelerated by global events such as the COVID-19 pandemic, has necessitated that clinicians across various disciplines, including those in primary care and behavioral health, integrate some form of telehealth intervention into their practice. This article aims to explore key insights for mastering telehealth in behavioral health, focusing on ethical guidelines, diversity, equity, and inclusion (DEI) considerations, and the adaptation of clinical interventions. Specific attention will be given to trauma treatments, EMDR, and play therapy, alongside a discussion of various virtual platforms and, crucially, techniques for fostering rapport and human connection in teletherapy.

The growth of telehealth has been exponential, offering unprecedented access to mental health services for individuals who might otherwise face significant barriers. These barriers can include geographical distance, transportation challenges, physical limitations, or privacy concerns. The ability to deliver care remotely has not only expanded the reach of behavioral health professionals but has also introduced a new set of complexities and considerations that demand careful navigation. This article will delve into these aspects, providing a comprehensive overview for clinicians seeking to enhance their telehealth practice.

Telehealth Behavioral Health Case Study

To provide a practical framework for applying the concepts discussed, we will follow a case study involving Daniel, an 8-year-old Latino male. Daniel's primary concern is increased anxiety and behavioral disruptions at school following witnessing domestic violence in his home. He was recently referred by his school counselor due to noticeable anxiety, a decrease in school performance, and aggressive behaviors towards his classmates.

Daniel's mother, Sofia, scheduled a telehealth session due to transportation barriers and privacy concerns that prevented in-person visits. The family resides in a rural community with limited access to mental health services, highlighting the critical role telehealth can play in bridging service gaps. As we proceed through the various sections of this article, we will revisit Daniel's case to illustrate how ethical considerations, DEI strategies, and adapted clinical interventions can be effectively applied in a real-world telehealth scenario.

Ethics Codes

Ethical practice forms the cornerstone of all clinical work, and its importance is amplified in the context of telehealth. Every major behavioral health profession has, to our knowledge, addressed telehealth within its ethics code. Clinicians are strongly advised to consult their specific ethical guidelines to ensure compliance and best practice. Resources for various professional organizations include:

• American Association for Marriage and Family Therapy (AAMFT)
• American Counseling Association (ACA)
• American Psychological Association (APA)
• National Board for Certified Counselors (NBCC)
• National Association of Addiction Professionals (NAADAC)
• National Association of Social Workers (NASW)

Additionally, clinicians must be aware of and adhere to their state-specific laws and administrative rules governing telehealth practice. These guidelines provide the foundational framework for ensuring ethical and responsible service delivery in the virtual environment.

Ethical and DEI Considerations – Brief Review

Ethical practice is foundational, particularly in telehealth. It is paramount to ensure privacy and confidentiality, which encompasses not only the use of secure video platforms but also safeguarding the virtual workspace. Clinicians must clearly communicate informed consent, detailing telehealth-specific risks and limitations. Proper documentation is essential to meet compliance standards and ensure quality care within one's organization or practice.

Diversity, Equity, and Inclusion (DEI) are equally important. Clinicians must be mindful of cultural differences and language barriers, which can be even more challenging to detect in an online platform. Strategies such as culturally sensitive communication and providing resources in the client's preferred language are crucial. Awareness of digital literacy levels is also vital. While some older individuals may need assistance with computer technology, younger generations, though comfortable with cell phones or tablets, may find these devices less ideal for telehealth interventions. The goal is to meet the patient where they are, understanding their typical interaction with technology.

Accessibility challenges related to disability or limited technological resources must also be considered. In Daniel's case, residing in a rural community with limited access to technology underscores the need for tailored approaches. Clinicians must always adapt their approach on a case-by-case basis, even when working with a general population, to ensure that telehealth services are accessible and effective for all clients.

Case Study: Diversity, Equity, and Inclusion (DEI) in Telehealth

Daniel and Sofia represent a diverse cultural and socioeconomic background, making the application of DEI principles in telehealth particularly relevant. Practicing diversity, equity, and inclusion in telehealth necessitates culturally sensitive communication, ensuring that language is both accessible and inclusive. It also requires understanding cultural views on mental health. How do Daniel and his mother generally perceive mental health practitioners or accessing therapy services? This understanding is crucial, as it adds another layer to how they might interact with technology and how these two aspects converge.

Acknowledging barriers to service access, such as their rural location, is vital. Openly addressing any cultural stigma related to counseling can foster greater engagement and trust. Several questions arise when considering cultural considerations in telehealth sessions with Daniel and Sofia. One might consider potential stigma surrounding mental health discussions and familial dynamics. Who is involved in the treatment, and who might wish to be involved? In a brick-and-mortar setting, one might anticipate meeting only the mother and child, but in a digital format, several additional relatives might wish to participate. How does this dynamic translate to a virtual environment?

Culturally appropriate methods of emotional expression also warrant attention. To what extent are nonverbal cues captured on screen? If the clinician is only visible from the shoulders up, how might this limit the observation of whole-body dynamics or nonverbal communication beyond traditional talk therapy? These discussions are essential for ensuring a comprehensive understanding of the client's emotional world.

Socioeconomic factors significantly influence Daniel's engagement and access to telehealth. Internet access limitations, including the speed required to sustain a video conference, and device availability are critical considerations. Clinicians must assess what devices the family possesses and how they interact with the clinician's chosen platforms. Offering practical solutions, such as phone check-ins or leveraging community resources, is paramount if reliable telehealth connectivity becomes an issue. For instance, an organization might set up a room with a computer in a different location within a rural community, allowing clients to access telehealth services even without home internet. This creative problem-solving is vital, while also being mindful of limiting solutions that involve public spaces, such as libraries, where full privacy may not be guaranteed.

Informed Consent and Client Autonomy

Informed consent and client autonomy are fundamental to building a strong therapeutic alliance, whether in traditional or virtual therapy settings. It is imperative for the patient to clearly understand telehealth procedures. This includes detailing the session structure, such as the expectation of using a virtual waiting room or preparing microphones and video before the session begins. Confidentiality measures must be thoroughly explained; patients may not fully grasp the security protocols simply by seeing a portion of the clinician's screen. Transparency about the measures the clinician personally takes to safeguard privacy is invaluable.

Data privacy is another critical aspect. Patients should be informed about whether sessions are recorded (typically they are not without explicit consent) and that data is generally not retained. A thorough discussion of the risks and benefits of telehealth compared to in-person therapy is also essential. If a clinician has reservations about telehealth ultimately benefiting a patient, it is best not to proceed with this modality.

When working with minors, as in play therapy or trauma therapies, obtaining informed consent from parents or legal guardians and assent from the child is crucial. The comprehension level must be appropriate for each developmental stage. For example, when conducting sand tray therapy, the clinician should explain how the virtual experience might differ from an in-person session where direct guidance or coaching is possible.

Best practices for informed consent include providing written documents that clearly detail telehealth-specific concerns, as recommended by APA guidelines. Ample time should be allocated for questions, not just at the intake or the beginning of treatment, but throughout the therapeutic process. This ongoing dialogue allows patients to express their comfort levels and helps gauge whether telehealth remains a suitable fit. Ultimately, ensuring that the client and caregiver clearly understand their rights and roles in telehealth services is paramount.

Confidentiality and Privacy

Confidentiality and privacy are paramount in telehealth. Practitioners must utilize secure, encrypted communication platforms that comply with HIPAA regulations. The era of using platforms like FaceTime for therapy is long past; secure options such as Zoom for business and healthcare, and other specialized platforms, are now standard. A list of hyperlinked resources will be provided at the end of this article, offering various platforms, some specifically designed for interventions like EMDR, bilateral stimulation aids, or group therapy modalities.

It is crucial to clearly communicate potential limitations of confidentiality in telehealth. This includes addressing accidental disclosures if someone enters the client's private space during a session. Clinicians should prepare for scenarios such as a patient attempting to find privacy in a public restroom, as this highlights the need for continuous assessment of the confidentiality of the client's environment. If a client is interrupted, any sensitive discussions should be paused to ensure no one overhears the private conversation. Particular attention must be paid to privacy issues in child and trauma-focused therapies, as sensitive disclosures may raise additional confidentiality concerns.

Best practices involve confirming that the client has a confidential and secure environment, free from disruptions, for each session. This might involve a virtual tour of the space. Regular reminders about the importance and limitations of confidentiality are essential, especially for minors and trauma survivors, ensuring they understand who has access to session content. Just as in traditional therapy, minors must understand that parents will be contacted in certain situations where confidentiality must be breached, clarifying that this does not mean parents will be brought into the video session without the child's knowledge.

Competence and Professional Boundaries

Ensuring professional competence in using telehealth technology and platforms is vital. This includes proficiency in technical troubleshooting and ethical decision-making within a virtual environment. It is advisable to conduct some of this troubleshooting during the initial intake to establish a safe environment, confirm good internet speeds, and ensure the patient is comfortable interacting on screen.

Clinicians must also recognize the limitations of telehealth in accurately assessing nonverbal cues, particularly in child therapy or trauma work, and adjust their practice accordingly. Patients do not need to be so close to the screen that only their head is visible. If an intervention involves bilateral stimulation or "butterfly hugs," a conversation should occur at the outset to determine the best setup for the technology, allowing the patient or parent to arrange it before the session. This proactive approach prevents the patient from feeling pressure to perform correctly while simultaneously discussing sensitive information. The goal is to avoid creating anticipatory anxiety related to the technology.

Maintaining clear professional boundaries in virtual interactions, especially regarding out-of-session communications, is equally important. Best practices include pursuing ongoing training and certification specific to telehealth best practices and ethical standards. For those engaging in specialty interventions, consulting the accrediting bodies or developers of those interventions for telehealth guidance is highly encouraged, as most now offer relevant literature. Establishing clear communication guidelines and protocols for session scheduling, rescheduling, and after-hours contact is also crucial. While the virtual format may make it seem easier for patients to text, email, or call, clinicians must clearly define these limitations, just as they would in standard therapy.

Trauma-Informed Ethical Practices

Applying trauma-informed care principles to telehealth practice is essential, prioritizing safety, transparency, and client empowerment. This guidance, derived from SAMHSA, emphasizes that patients must feel comfortable engaging in this modality, a comfort that may take several sessions to achieve. The aim is to ensure forward progress in the therapeutic journey.

It is crucial to acknowledge that trauma work via telehealth carries a risk of re-traumatization if not carefully managed. Clinicians must consider potential technological breakdowns, lag, or loss of connection during deep meditative states. These possibilities warrant upfront discussions with patients. A backup plan, such as a phone call to continue the session, should always be in place to prevent patients from feeling stranded during critical moments of trauma processing.

Best practices involve utilizing virtual grounding and containment strategies specifically designed for telehealth settings. These adaptations help patients remain grounded during sessions. Regular monitoring for emotional safety is also vital, requiring clinicians to adjust their therapeutic approach to reduce client distress and ensure supportive follow-up care.

Ethical Considerations for Child Therapy and Play Therapy

Child therapy and play therapy in a telehealth format often require significant adaptation. Direct physical interaction, as in traditional in-person sessions, is typically not possible. The primary goal is to maintain therapeutic effectiveness while upholding ethical standards. The Association for Play Therapy, in 2020, released recommendations for such adaptations, which clinicians are encouraged to consult.

Considering developmental appropriateness and age-specific confidentiality is paramount. Working with a 10-year-old differs significantly from working with a 3- or 4-year-old. The role of the parent or caregiver in facilitating the session may also increase, potentially involving more interaction between them and the child than would typically occur in an office setting.

Best practices include selecting age-appropriate virtual play interventions and ensuring caregiver involvement in creating a therapeutic space conducive to online play therapy. Clear communication of expectations and boundaries for both caregivers and child clients regarding interactions within teletherapy sessions is essential. For instance, clinicians might advise parents that while they can assist with setting up the digital format, they should not simply "pop in and out" of the session to maintain child confidentiality. A brief 5-minute start or close with parents, with the middle of the session dedicated solely to the clinician and child, can help maintain this boundary.

Ethics, Diversity, Equity, and Inclusion (DEI)

Ethically sound telehealth practice must actively consider diversity, equity, and inclusion by recognizing the multifaceted barriers clients face. These barriers can include language differences, which may necessitate a translator, similar to in-office settings. Cultural stigma surrounding mental health is another significant factor; clinicians must understand how patients perceive accessing therapy in general, and then layer on how they feel about accessing telehealth specifically. Socioeconomic constraints, such as the cost of devices and internet access, also impact access to telehealth. Clinicians should strive to level the playing field as much as possible, exploring creative approaches such as directing clients to community resources or designated office spaces where technology can be accessed.

Addressing potential implicit biases in telehealth interactions is crucial, as these can influence the therapeutic alliance or clinical judgment. For example, if a clinician expects a patient to maintain direct eye contact with the camera, but the patient's cultural background dictates a more deferential interaction style, the clinician must be well-versed in these nuances. Understanding that this is not a lack of respect but a cultural norm allows for appropriate adjustment of expectations.

Best practices involve actively engaging in cultural humility and seeking education on culturally responsive telehealth strategies. The growing body of research in this area provides valuable insights into interaction strategies for specific populations in telehealth. Providing equitable services is also paramount, which includes accommodating client needs through language assistance, culturally appropriate interventions, and flexible scheduling to address access barriers. This might mean adjusting session times to align with when community resources for technology are available.

Crisis Management and Ethical Decision-Making

Telehealth practitioners must anticipate and proactively prepare for crisis situations during virtual therapy sessions, especially when working with trauma and high-risk client populations. This guidance is reinforced by APA articles from 2017. It is crucial to clarify protocols for managing crises remotely, including suicidal ideation, threats of harm, or disclosures of ongoing abuse. When geographical distance is a factor, safety plans with nearby support systems may need to be established to assist at-risk patients.

Best practices involve creating and clearly communicating telehealth-specific crisis response plans. These plans should include immediate contact numbers, such as suicide hotlines or other interventions typically provided in face-to-face settings. Procedures for emergency intervention must be clearly outlined, including agreements to remain online beyond the scheduled therapeutic hour if necessary, to ensure the patient's safety and stabilization, and potentially arranging for a safe person to join them. Detailed, written crisis protocols outlining exact steps for both the client and clinician to follow in urgent situations are also essential.

Ethics Summary

Ethical practice within telehealth is critical for ensuring the delivery of effective, safe, and culturally responsive behavioral health services. By diligently adhering to established ethical guidelines, behavioral health clinicians can successfully provide trauma-informed care, implement child-focused interventions, and offer diversity-inclusive therapy services remotely. It is imperative for clinicians to engage in continuous professional development through regular training and to maintain familiarity with current ethical codes. This ongoing commitment provides the necessary foundation for sound ethical decision-making within the evolving landscape of telehealth practice.

Case Study: Best Practices and Ethical Considerations in Telehealth

Returning to our case study, as we meet with Daniel and his mother for their initial telehealth appointment, it is critical to integrate ethical guidelines and best practices. The first step involves obtaining clear and specific informed consent from Sofia regarding the nuances of telehealth sessions. This conversation must ensure she thoroughly understands the potential risks, the privacy safeguards we will implement, and the privacy measures she should also take. Additionally, a plan for addressing emergencies or technological interruptions must be established. Utilizing an encrypted, HIPAA-compliant telehealth platform and clearly outlining data security measures will enhance trust in the telehealth process.

To handle informed consent with Daniel's mother and ensure her understanding, a clear, age-appropriate explanation of telehealth, its functionality, and what to expect should be provided. Verification of understanding can be achieved by asking Sofia to paraphrase or recite her understanding of how the telehealth sessions will work, with this consent thoroughly documented.

To confirm confidentiality and data security with Daniel's family, it is essential to clarify that the platform is encrypted and to discuss privacy settings so they understand that session content is not shared with others. The clinician's unwavering commitment to confidentiality should be emphasized. Furthermore, providing a written detailed explanation or a frequently asked questions (FAQ) document can be a valuable resource, particularly if telehealth is a regular component of the clinician's practice.

Telehealth for Trauma Treatment and EMDR

We now turn our attention to Eye Movement Desensitization and Reprocessing (EMDR), specifically examining how this powerful, evidence-based trauma intervention can be adapted for telehealth settings. While early research and interventions for EMDR were primarily conducted face-to-face, telehealth has significantly broadened its accessibility, providing essential trauma treatment to clients who might otherwise face limited access due to geographic, physical, or logistical barriers. Shapiro's 2017 article, referenced at the end of this document, provides valuable insights into this expansion. Successfully translating EMDR to virtual environments necessitates thoughtful modifications, specialized tools, and careful ethical considerations to ensure both effectiveness and client safety.

EMDR Brief Summary

EMDR is an evidence-based therapeutic modality primarily used for addressing trauma and distressing experiences. Developed by Francine Shapiro, EMDR integrates bilateral stimulation, such as guided eye movements across the midsection, to facilitate the brain's natural processing mechanisms. This approach enables clients to reprocess traumatic memories, thereby reducing their emotional intensity and associated distress. EMDR has demonstrated high effectiveness as an evidence-based intervention for post-traumatic stress disorder (PTSD), anxiety disorders, and depression, often leading to a more rapid alleviation of symptoms compared to some traditional therapies. Its incorporation expands the therapeutic toolbox, offering a powerful resource for supporting clients on their healing journey.

How to Obtain Training

EMDR training is typically available to licensed behavioral health professionals, including psychologists, social workers, counselors, marriage and family therapists, and psychiatric nurses. The training process generally involves completing an EMDR International Association (EMDRIA) approved course. These courses consist of intensive workshops that combine didactic learning, live demonstrations, supervised practice, and consultation sessions. Training usually spans several weekends or a week-long intensive program, followed by substantial supervised clinical practice sessions to ensure competency. After initial training, ongoing supervision and consultation are crucial for therapists to refine their skills. Completing this comprehensive training equips clinicians with a robust, evidence-based therapeutic tool that significantly enhances their ability to work with patients experiencing trauma and anxiety.

Virtual Bilateral Stimulation Methods

Bilateral stimulation is at the core of EMDR treatment. Traditionally, this involves eye movements guided by a therapist in person. In telehealth, several virtual methods are utilized. Visual methods may include following a therapist's finger across the webcam or using digital platforms specifically designed for EMDR, some of which feature tools that facilitate back-and-forth eye tracking, such as RemotEMDR or BilateralStimulation.io. These resources are listed in the references section. Another common method involves auditory bilateral stimulation, where clients use headphones to listen to alternating audio tones, facilitated by specialized EMDR platforms. Clinicians may need to provide additional coaching to patients on setting up their virtual environment, including the use of headphones, to achieve this.

Tactile stimulation offers another avenue, involving methods clients can perform themselves, such as alternately tapping on their shoulders or legs, often referred to as a "butterfly hug" technique. All these methods aim to activate bilateral brain activity, which is essential for EMDR processing, while maintaining client comfort and engagement in a virtual format. It is crucial to clearly demonstrate and practice virtual bilateral techniques with clients before starting treatment. This proactive approach prevents the first exposure to these techniques from coinciding with the discussion of a traumatic experience, thereby reducing anticipatory anxiety. The goal is to ensure clients feel comfortable and competent with the technology before engaging in sensitive processing.

These methods have proven effective when clearly demonstrated, practiced, and discussed with clients prior to therapy sessions, as highlighted in Parnell's research. The therapist's role is to select the bilateral stimulation method most suitable for the client's comfort, preference, and technological capabilities.

Telehealth Adapted EMDR Protocol

Adapting the standard EMDR protocol, which typically includes eight phases—history taking, preparation, assessment, desensitization, installation, body scan, closure, and reevaluation—to a teletherapy format requires maintaining fidelity to the original methodology. While adaptations are necessary, the fundamental phases must still be followed, just as they would be with an in-person patient. Telehealth adaptations primarily focus on utilizing secure virtual environments to ensure privacy and compliance with HIPAA regulations. It is crucial to adequately prepare clients for what to expect during remote sessions.

Reinforcing the structure of EMDR virtually and thoroughly explaining each phase is critical. Adjusting the pacing of the session and transparently communicating these adjustments to the patient empowers them with information about the pros and cons of the virtual format. If a patient ultimately decides that an in-person approach is preferable, that wish should be respected.

Remote Resourcing and Stabilization

A critical component of EMDR therapy, especially when addressing severe trauma, is ensuring clients possess effective emotional regulation tools. In telehealth settings, this may involve guiding clients through virtual mindfulness exercises, grounding techniques, or guided imagery. Helping the client create a "calm place" and "safe place" virtually can significantly enhance their resilience. This is particularly important when discussing sensitive, trauma-related issues, as it helps reduce emotional flooding during processing and ultimately reinforces the client's sense of agency.

This process requires regular practice and consistent reinforcement of these resources at the beginning and end of sessions to help clients manage distress. When considering adaptations, it may be necessary to dedicate more time to ensuring the initial starting point or location is quiet and confidential, fostering a calm environment conducive to entering a meditative headspace.

Trauma-Focused Telehealth EMDR

When utilizing EMDR specifically for trauma-focused therapy via telehealth, special attention must be given to remote containment strategies, crisis planning, and any immediate safety measures that might be necessary if the patient experiences emotional flooding during the session. A clear plan must be in place to manage such situations and guide the patient back to a calm state.

During trauma-focused sessions, emotional activation is expected. As clinicians, we must carefully assess a client's readiness and stability before initiating EMDR online. Clear emergency protocols and crisis planning must be firmly established, and clients should be provided with explicit guidelines or frequently asked questions (FAQs) regarding crisis procedures. This might include providing resources such as the National Suicide Hotline (988) and establishing a specific telehealth safety plan to ensure immediate access to crisis interventions if needed.

Virtual EMDR Group Protocols

Virtual EMDR group therapy is an emerging and increasingly beneficial approach, particularly in scenarios involving shared trauma, such as natural disasters, community violence, or supporting healthcare workers during events like the COVID-19 pandemic. Much of the research in this area originated from the need to provide an outlet for highly fatigued and overtaxed healthcare workers to process shared experiences with peers.

Group EMDR protocols necessitate special attention to informed consent regarding confidentiality and group safety. It is crucial to ensure that the virtual environment is private, meaning that individuals in the background of one participant do not have access to the confidential information of other participants. This mirrors the in-person imperative to prevent information from leaving the group. Facilitators must ensure a secure environment, clarify boundaries, roles, and expectations prior to initiation, and continuously reinforce confidentiality, especially given the increased number of linked devices in a group format.

EMDR Telehealth Ethics Reminder, Resources and References

For further guidance on EMDR telehealth ethics, several key resources are available. The EMDR International Association (EMDRIA) provides specific guidelines on virtual EMDR, accessible through their website. Additionally, the American Psychological Association (APA) offers comprehensive telepsychology guidelines that are highly relevant.

In terms of specific EMDR telehealth platforms and tools, several options exist. RemotEMDR is a dedicated online EMDR therapy platform. BilateralStimulation.io offers a free virtual bilateral stimulation tool, and Easy EMDR provides an online platform for visual and auditory bilateral stimulation.

For client safety and crisis resources, the National Suicide Prevention Lifeline (988) offers 24/7 crisis support. The Crisis Text Line provides text-based crisis support by texting HOME to 741741.

Recommended literature for clinicians seeking to deepen their understanding and training in EMDR includes:

• Shapiro, F. (2017). Eye Movement Desensitization and Reprocessing (EMDR) Therapy: Basic Principles, Protocols, and Procedures (3rd ed.). Guilford Press.
• Leeds, A. (2016). A Guide to the Standard EMDR Therapy Protocols for Clinicians, Supervisors, and Consultants (2nd ed.). Springer Publishing Company.
• Parnell, L. (2013). Attachment-Focused EMDR: Healing Relational Trauma. W.W. Norton & Company.

These resources provide comprehensive information for those looking to pursue more training or enhance their EMDR practice in a telehealth context.

Case Study: Effective Rapport-Building via Telehealth

Returning to Daniel and Sophia's case, building rapport through telehealth requires very intentional efforts. Sessions can begin with engaging, age-appropriate icebreakers. For instance, asking Daniel about his favorite hobbies or inviting him to a "virtual show and tell" where he can share objects or activities from his home that he wouldn't typically bring to an in-person session can be highly effective. This might include introducing pets, which can be a powerful way to build rapport and bond with the patient.

Consistently maintaining direct eye contact, assuming it is culturally appropriate, involves looking into the camera and modeling how to interact on screen. This clearly demonstrates to Daniel that the clinician is focused and attentive, serving as positive modeling not only for children but also for adults, showing a high comfort level with the technology and a genuine presence.

To modify communication style for building trust and rapport online with a child client, clinicians should adjust their voice tone, utilize visual gestures, and employ expressive facial expressions. Incorporating interactive elements that foster emotional connection is also crucial.

Regarding virtual tools or activities that might engage Daniel effectively, the internet offers numerous possibilities. Shared online games, such as chess, checkers, or word games, can be beneficial, provided they are compatible with a HIPAA-compliant platform. Digital drawing tools and storytelling applications, akin to a journaling practice, can also enhance engagement and make sessions more enjoyable for Daniel.

Case Study: Trauma Therapy via Telehealth

In addressing Daniel's trauma from witnessing domestic violence, a trauma-informed care approach specifically adapted for telehealth is essential, guided by best practice guidelines. Before delving into traumatic memories, it is paramount to ensure Daniel is in a safe, comfortable, and confidential space at home. Virtual grounding exercises should be employed, teaching Daniel breathing or sensory grounding skills to manage distress. This foundational work and coaching, which might be more extensive than in face-to-face therapy, are crucial to ensure that if Daniel becomes overwhelmed by the additional element of technology, he can utilize techniques like deep breathing to regain presence in the session.

To adapt trauma-focused interventions for Daniel via telehealth, clinicians might use visual aids, such as a breathing exercise, and virtual grounding techniques like counting backward from 10. Each step should be clearly demonstrated over video to eliminate any ambiguity, ensuring Daniel does not have to guess how to perform the technique.

Telehealth-specific safety measures must also be considered. Working collaboratively with Sofia, Daniel's mother, to establish a clear safety plan is vital. This plan should ensure Daniel has access to supportive resources and emergency contacts in case of any distress he might experience during sessions, particularly given the potential for traumatic events related to domestic violence to arise.

Adapting Child and Play Therapy for Virtual Care

Child and play therapy necessitate creativity when transitioning to an online format. The integration of engaging, interactive virtual activities that align with the child's developmental stage is crucial. Encouraging caregiver involvement when appropriate facilitates meaningful therapeutic interaction, even in a remote setting. Examples of such activities include guided drawing, where a child might draw their family and describe its members, or a more specific prompt like drawing how they wish to be perceived by peers. Interactive storytelling or bibliotherapy can also be employed, perhaps through shared digital storybooks or collaborative drawing platforms. Virtual sand tray therapy, using digital tools that allow children to select and place symbolic objects, helps externalize internal experiences. Emotion-focused games, virtual puppet therapy, and mindfulness or virtual yoga sessions are also valuable options. Clinicians must guide parents in setting up a conducive therapy space at home to maximize effectiveness and ensure safety, potentially sending FAQs or emails in advance.

Modifying Therapy Techniques for Virtual Sessions

When transitioning play therapy to a virtual platform, careful selection of methods that are engaging, interactive, and developmentally appropriate is essential. Virtual interventions must be clearly structured and easy for the child to follow remotely. The principle of "less is more" often applies; steps should be easily digestible. It is important to anticipate and resolve any technology challenges. If additional interactions involving hyperlinks or navigation to other areas are incorporated, their number should be limited to avoid overwhelming the child or parent. Selecting virtual tools such as digital drawing platforms, online stories, and interactive games can significantly enhance engagement and outcomes, offering age-appropriate alternatives to standard talk therapies.

Integrating Caregivers Effectively

Caregivers, especially for children, play a crucial role in virtual therapy. Their involvement in teleplay therapy sessions is paramount, as virtual therapy takes place within the home environment, making caregiver support central to therapeutic activities. Clinicians can engage parents through phone calls or virtual video calls to outline session intentions and specific timestamps for their involvement. Gil's 2015 article provides good examples of how to prepare and converse with family members or caregivers. For instance, caregivers might set up a safe, comfortable therapy environment, assist with technology setup, and reinforce session activities. In a virtual sand tray therapy scenario, extensive coaching with the parent might enable them to facilitate the physical interaction that would otherwise occur in a face-to-face setting, with the practice extending as homework.

Tele-Play Therapy Examples

Several tele-play therapy examples can be effectively adapted for virtual settings. Guided drawing and expressive arts encourage children to express emotions through interactive drawing tasks. Clinicians might prompt a child to create a safe space or draw their feelings, then discuss these creations to gain insights into their emotional world. Interactive storytelling and bibliotherapy can involve digital storybooks or shared screens, allowing for collaborative drawing or storytelling. Virtual sand tray therapy, utilizing digital platforms, enables children to select and place symbolic objects, helping them externalize internal experiences safely. Emotion-focused games, such as feeling charades or emotion matching, promote emotional identification and expression. Virtual puppet therapy offers a unique dramatic element, leveraging the unseen space to facilitate safe emotional expression through puppets. Finally, mindfulness and virtual yoga, through simple exercises or brief child-friendly sessions, can help reduce anxiety and improve emotional regulation. Clinical judgment is always essential to determine the best fit for the child, their family's comfort, and their overall interaction and growth.

Family and Parent-Child Interactive Teletherapy

Family involvement through structured interactive teletherapy can be a powerful tool, particularly in addressing relationship dynamics. This approach can help strengthen attachment bonds and reinforce session outcomes within the home environment. Various methods can facilitate family interaction on screen, including joint art projects, collaborative storytelling, or structured emotion-sharing tasks. Anything that promotes effective communication and supports family wellness can be beneficial.

Trauma-Focused Approaches and EMDR Adaptations

Shapiro's 2017 article highlights the significant therapeutic value of integrating trauma-informed strategies, such as virtual EMDR or trauma-focused Cognitive Behavioral Therapy (TF-CBT), adapted for telehealth. The article specifically discusses carefully adapted trauma processing techniques, including virtual bilateral stimulation through guided tapping activities or "butterfly hugs," which support children in safely exploring and processing traumatic memories remotely. Clinicians engaging in these trauma-related processing techniques via telehealth are strongly encouraged to consult this article for comprehensive guidance.

Considerations for Diversity, Equity, and Inclusion (DEI)

Adapting child and play therapy techniques virtually also requires careful attention to cultural sensitivity, diversity, equity, and inclusion. It is paramount to ensure that all activities are culturally relevant, inclusive, and sensitive to the family's background. This necessitates an open discussion at the outset of therapy, prompting clinicians to thoughtfully consider the cultural differences that may exist based on the patient in front of them.

Ethical Considerations in Virtual Child Therapy

Several ethical considerations are paramount in virtual child therapy. Confidentiality and privacy are critical, requiring the exclusive use of HIPAA-compliant telehealth platforms. Informed consent is equally crucial; caregivers must be fully informed about telehealth specifics, potential risks, and their responsibilities during sessions. They need to understand the pros and cons of engaging in this format, as convenience alone does not guarantee suitability for their presenting problems or symptoms. Competence is another key ethical pillar; clinicians must continuously develop their skills related to virtual care delivery, ensuring familiarity with technological platforms and the utilization of age-appropriate virtual therapy methods. Finally, safety protocols are essential. Clinicians must have a clear safety plan and established procedures for implementation should a crisis arise during a session.

Adapting Child/Play Therapy to Telehealth Wrap-up

As we conclude this section, it is evident that teleplay therapy offers innovative, accessible, and highly effective avenues for delivering therapeutic services remotely. Clinicians are strongly encouraged to continuously expand their telehealth toolkit through ongoing professional education, consulting with experienced colleagues, and seeking guidance from professional associations that have developed specific guidelines, such as the Association for Play Therapy and the National Child Traumatic Stress Network (NCTSN), which are excellent resources for ongoing training.

For Daniel's case, to facilitate play-based emotional expression, specific virtual interventions could include utilizing virtual sand tray tools, guided storytelling, and drawing platforms. In this scenario, such approaches could encourage Daniel to open up more emotionally and be more willing to explore his experiences, thereby building stronger rapport. To monitor and maintain engagement and emotional safety during virtual child therapy, clinicians should regularly observe Daniel's emotional reactions, frequently check his comfort level, and use rating scales or check-ins and check-outs. This continuous assessment, not just at the start of treatment but at each subsequent visit, helps gauge his comfort and the effectiveness of the therapeutic relationship.

Building Human Connection Virtually

Establishing a strong therapeutic alliance remains paramount in a virtual setting, just as it is in person. This involves building trust and rapport, increasing emotional attunement remotely, and effectively managing any virtual crises. When patients know that their clinician has a plan for managing emergencies, it fosters a sense of security and trust.

Telehealth Best Practices: Key Takeaways

To recap the essential elements for mastering telehealth in behavioral health:

• Quick review of ethical guidelines: Clinicians must regularly consult their specific ethical guidelines and state regulations to ensure compliant and responsible practice.
• Cultural responsiveness in telehealth: Understanding and adapting to diverse cultural backgrounds, language barriers, and digital literacy levels is crucial for providing equitable and effective care.
• Effective virtual therapeutic techniques: Employing creative, engaging, and age-appropriate interventions, especially for trauma and child therapies, is key to maintaining clinical effectiveness in a remote environment.

Ultimately, the aim is to create compassionate, effective, and ethical care remotely. The resources discussed throughout this article, including specific platforms for trauma-based interventions like EMDR and general ethical guidelines from organizations such as the APA, ACA, and NASW, provide invaluable support for clinicians in achieving this goal (NASW, 2021).

Telehealth Course Resources

Copy and paste the links into a new browser window.

Child and Play Therapy via Telehealth

• Virtual Sandtray Therapy: https://www.sandtrayplay.com
• Interactive Storytelling and Bibliotherapy: https://www.storybird.com
• Virtual Puppet Therapy: https://puppetools.com
• Online Playrooms and Interactive Games: https://toytheater.com
• Virtual Mindfulness and Yoga Activities: https://www.cosmickids.com

EMDR and Trauma-focused Telehealth Resources

• EMDR International Association (EMDRIA): https://www.emdria.org
• Virtual EMDR Platform: https://virtualemdr.com
• Trauma-focused Cognitive Behavioral Therapy (TF-CBT): https://www.nctsn.org/interventions/trauma-focused-cognitive-behavioral-therapy
• PTSD Telehealth Toolkit (Veterans Affairs): https://telehealth.va.gov

Telehealth Ethical Guidelines and Resources

• American Psychological Association (APA) Guidelines for Telepsychology: https://www.apa.org/practice/guidelines/telepsychology
• American Counseling Association (ACA) Code of Ethics (Telehealth): https://www.counseling.org
• National Association of Social Workers (NASW) Standards for Technology: https://www.socialworkers.org

References

American Counseling Association. (2014). ACA code of ethics. Retrieved from https://www.counseling.org/Resources/aca-code-of-ethics.pdf

American Psychological Association. (2017). Ethical principles of psychologists and code of conduct. Retrieved from https://www.apa.org/ethics/code

American Psychological Association. (2020). Publication manual of the American Psychological Association (7th ed.). https://doi.org/10.1037/0000165-000

American Psychological Association. (2021). Guidelines for the practice of telepsychology. Retrieved from https://www.apa.org/practice/guidelines/telepsychology

Association for Play Therapy. (2020). Play therapy best practices. Retrieved from https://www.a4pt.org/page/PTBestPractices

EMDR International Association. (2020). EMDR therapy and telehealth guidelines. Retrieved from https://www.emdria.org

Gil, E. (2015). Play in family therapy (2nd ed.). Guilford Press.

Landreth, G. L. (2021). Play therapy: The art of the relationship (4th ed.). Routledge.

Leeds, A. (2016). A guide to the standard EMDR therapy protocols for clinicians, supervisors, and consultants (2nd ed.). Springer Publishing Company.

National Association of Social Workers. (2017). NASW standards for technology in social work practice. Retrieved from https://www.socialworkers.org

National Association of Social Workers. (2021). NASW code of ethics. Retrieved from https://www.socialworkers.org/About/Ethics/Code-of-Ethics

National Child Traumatic Stress Network. (2021). Trauma-focused cognitive behavioral therapy. Retrieved from https://www.nctsn.org/interventions/trauma-focused-cognitive-behavioral-therapy

Norwood, C., Moghaddam, N. G., Malins, S., & Sabin‐Farrell, R. (2020). Working alliance and outcome effectiveness in videoconferencing psychotherapy: A systematic review and noninferiority meta‐analysis. Clinical Psychology & Psychotherapy, 27(6), 797–808. https://doi.org/10.1002/cpp.2456

Parnell, L. (2013). Attachment-focused EMDR: Healing relational trauma. W.W. Norton & Company.

Perry, B. D., & Hambrick, E. P. (2008). The neurosequential model of therapeutics. Child Trauma Academy. Retrieved from https://childtrauma.org

Shapiro, F. (2017). Eye movement desensitization and reprocessing (EMDR) therapy: Basic principles, protocols, and procedures (3rd ed.). Guilford Press.

Substance Abuse and Mental Health Services Administration. (2014). SAMHSA’s concept of trauma and guidance for a trauma-informed approach. Retrieved from https://store.samhsa.gov/sites/default/files/d7/priv/sma14-4884.pdf

Veterans Affairs Telehealth Services. (2021). PTSD and trauma telehealth toolkit. U.S. Department of Veterans Affairs. Retrieved from https://telehealth.va.gov

Additional Current References

These references were added as additional information on the topic for course participants; the presenter did not use them in developing the course.

Adedoyin, A. C., Wynn, S., Adunlin, G., Adegboyega, A., Holly, H., Makanjuola, D. I., Adedoyin, O. O., Bolaji, O., Olawoyin, E., & Makanjuola, O. E. (2025). Telehealth access inequality for african americans in rural areas: Interventions from an interprofessional education perspective. Journal of Human Behavior in the Social Environment. Advance online publication. https://doi.org/10.1080/10911359.2025.2470901

Choi, S., Hussain, S., Wang, Y., D'Aunno, T., Mijanovich, T., & Neighbors, C. J. (2025). Telehealth disparities in outpatient substance use disorder (sud) treatment among medicaid beneficiaries during covid-19. Substance Use & Misuse. Advance online publication. https://doi.org/10.1080/10826084.2025.2478603

Palfai, T. P., Kratzer, M. P. L., Taylor, J. L., Otis, J. D., & Winter, M. R. (2025). Addressing pain and heavy drinking among patients in hiv-care: A pilot study of an integrated telehealth intervention. AIDS and Behavior. Advance online publication. https://doi.org/10.1007/s10461-025-04660-8

Torres, V. A., Coe, E., Jackson, J., Leonard, K., Rostockyj, J., Swensen, K., Meyer, E., Gulliver, S. B., & Jones, S. (2025). Data‐informed selection of evidence‐based treatments for posttraumatic stress disorder and co‐occurring symptoms. Journal of Traumatic Stress. Advance online publication. https://doi.org/10.1002/jts.23133

Young, J. F., Jones, J. D., Schwartz, K. T. G., So, A., Dysart, G. C., Kanine, R. M., Gillham, J. E., Gallop, R., & Davis, M. (2025). Telehealth-delivered depression prevention: Short-term outcomes from a school-based randomized controlled trial. Journal of Consulting and Clinical Psychology, 93(4), 213–225. https://doi.org/10.1037/ccp0000913

This text-based course is an edited transcript of the webinar, Drug Culture and the Culture of Recovery: A Sociological Perspective, presented by Sophie Nathenson, PhD on February 28. 2025.

Disclosures

• Presenter Disclosure: Financial: Dr. Sophie Nathenson, Ph.D, received an honorarium for presenting this course. Sophie Nathenson is the founder and Director of the Population Health Management BS Program and the Population Health Management Research Center at Oregon Tech. She is also the owner of Widespread Wellness Consulting, providing career mentorship and education for individuals and groups working on promoting social, physical, emotional, and mental well-being. Non-financial disclosures: Sophie Nathenson has no relevant non-financial relationships to disclose.

• Content Disclosure: This learning event does not focus exclusively on any specific product or service.

• Sponsor Disclosure: There is no external sponsor for this course.

Limitations & Risks

• Substance use is complex and multifaceted, and impacts each individual differently. Practitioners must recognize their biases and triggers, as well as the client's triggers, when working with SUD and recovery. 

• Recovery methods vary (12-step programs, harm reduction, medication-assisted treatment, etc.), and debates can arise between different ideological approaches; therefore, practitioners must identify the most appropriate method for each client.

• Drug and recovery culture intersect with healthcare, criminal justice, social services, and policy. This webinar will not comprehensively cover all these areas; therefore, additional training is encouraged.

• Practitioners should exercise cultural humility at all times and respect clients’ varying cultures and their cultural perceptions of substance use and recovery.

Learning Outcomes 

After this course, participants will be able to:

1. Describe the concept of drug culture and recovery culture

2. Identify four ways that culture can impact substance abuse

3. Explain how understanding drug culture can aid in substance abuse recovery

Introduction

Substance use disorder, a complex and multifaceted phenomenon, impacts individuals in diverse ways. While biological and psychological factors are often at the forefront of understanding and treatment, a crucial, yet sometimes overlooked, dimension is the sociological perspective. This article, drawing from the insights of medical sociology, aims to illuminate the profound influence of culture on both drug use and the journey of recovery. By shifting the lens from individual pathology to broader societal dynamics, we can gain a more comprehensive understanding that enhances therapeutic alliances, informs assessment strategies, and ultimately fosters more effective interventions.

The presentation of this material is rooted in a medical sociological framework, which examines the intricate relationship between health and society. Unlike approaches that primarily focus on individual biological or psychological predispositions, medical sociology investigates health outcomes at the population level. This involves tracing health issues back to their societal and community origins. This perspective does not negate the importance of individual factors, but rather integrates them within a multifactorial understanding, acknowledging the interplay of psychology, biology, and even spirituality. The central tenet is that societal structures, cultural norms, and environmental contexts significantly shape individual experiences with health and illness, including substance use and recovery.

The concept of socialization, the lifelong process through which individuals acquire the norms, values, behaviors, and social skills appropriate to their society, is fundamental to this sociological view. We learn how to act in society through various agents of socialization, including family, friends, educational institutions, workplaces, and media. Culture, defined as the shared way of life of a particular group of people, encompasses their values, beliefs, and material expressions. When considering drug use, it becomes imperative to analyze how these social and cultural environments influence individual behaviors and perceptions.

Treatment and intervention strategies, whether in therapy, counseling, medical care, or educational settings, tend to achieve greater success when the cultural and social environment of the individual is taken into account. Individuals, upon returning to their pre-treatment environments, often face significant challenges in sustaining their recovery if those environments remain unchanged or unaddressed. Therefore, a holistic approach necessitates an understanding of the broader social fabric that envelops the individual's experience.

Sociological Perspective

The sociological perspective offers a macro-level view, focusing on society as the big picture. This approach contrasts with micro-level analyses that delve into individual differences in biology or psychology. Instead, it examines social factors such as age, gender, sexuality, and socioeconomic status (SES), which is a composite measure encompassing income level, wealth, and occupation. By comparing groups based on these social categories, sociologists analyze patterns and outcomes, such as rates of drug use. It is crucial to emphasize that this group-level analysis does not imply homogeneity among individuals within a social category. Rather, it highlights the statistical tendencies and broader societal influences that may contribute to certain health behaviors.

For instance, within medical sociology, the focus is consistently on health outcomes and behaviors. The sociological perspective posits that treatment, therapy, counseling, medical care, or education becomes more successful when the cultural and social environment is explicitly considered. Individuals, after receiving care, return to their existing environments. If these environments remain unaddressed, maintaining the successes achieved in treatment can become a significant challenge. This underscores the need for interventions that extend beyond the individual to encompass their social and cultural contexts.

Social Factors in Drug Use

A range of social factors demonstrably correlates with higher rates of drug use at the group level, though these are not deterministic for any single individual. Poverty and lower socioeconomic status, for example, are consistently associated with increased drug use. It is also observed that different types of drugs may be patterned by social class, indicating a nuanced relationship between economic standing and substance choice.

Social alienation or rejection represents another significant predictor at the group level. A lack of meaningful social connection or experiences of ostracization can contribute to vulnerability to drug use. Similarly, low academic achievement, particularly when viewed as a societal pattern rather than an individual failing, is linked to higher rates of substance use. The prevalence of crime and violence within a neighborhood or at a broader societal level also serves as a social determinant of drug use.

Levels of low religiosity are predictive of drug use, suggesting that spiritual or communal affiliations may offer protective factors. Furthermore, the strength of an individual's social connections, encompassing not only their immediate social networks but also their involvement in community organizations, plays a crucial role. Greater involvement in such groups tends to correlate with an increased capacity to resist negative peer pressure and make choices aligned with personal well-being. Conversely, weak social support and isolation are significant risk factors.

Experiencing homelessness presents a particularly acute example of environmental influence. Individuals experiencing homelessness are exposed to numerous elements that can drive drug use, including the need for warmth, safety, and a means of staying awake to avoid danger. Drugs can also become a primary avenue for social interaction and connection in such circumstances.

Adverse childhood experiences (ACEs) represent a powerful set of social factors. These include witnessing abuse, experiencing abuse as a child, or living with a family member who has a substance use disorder. Research consistently demonstrates that a higher number of ACEs significantly increases an individual's risk of initiating drug use and developing addiction. The impact of ACEs extends beyond immediate behavioral responses; these experiences can fundamentally alter brain development and genetic expression. This highlights how social factors and the social environment are not merely external influences but can profoundly reshape an individual's neurobiology and genetic predispositions, further linking them to drug use and addiction. This intricate connection underscores the deep physiological impact of social adversity.

Culture

Culture, the central theme of this discussion, is broadly defined as a way of life shared by a group. This encompasses three primary components: values, beliefs, and material culture. Values represent what a group deems important, guiding their priorities and actions. Beliefs are what a group considers true, forming their understanding of the world and their place within it. Material culture, on the other hand, refers to the tangible aspects of a culture, ranging from clothing and food to objects and technologies. These elements collectively define the shared reality and practices of a cultural group.

Cultural Competency

The concept of cultural competency, typically associated with knowledge, communication, and connection with diverse populations, gains a critical new dimension when applied to drug culture. While existing literature and training often focus on factors like race and ethnicity, there is a notable gap in addressing drug culture as a distinct and powerful cultural influence. Cultural competency, in its essence, involves understanding cultural dynamics to benefit the therapeutic alliance. It does not require a practitioner to be an expert in every culture, which can, in fact, reinforce power differentials. Instead, a foundational awareness of the larger cultural issues affecting individuals can significantly enhance the therapeutic relationship.

Cultures exert a profound influence on the manifestation of various disorders, patterns of substance use, and the effectiveness of treatment-seeking behaviors. Drug cultures, in this context, are as potent and significant as traditional factors like race and ethnicity in shaping health disparities and influencing individual experiences. Recognizing this allows for a more nuanced approach to serving all individuals, irrespective of their backgrounds, philosophies, or the specific cultural contexts of their substance use.

Drug Cultures

Drug cultures are defined as a set of shared values, beliefs, customs, and rituals specific to the use of a particular substance. These cultures have a long and varied history, existing across different historical periods and geographical locations. Their characteristics vary significantly depending on the specific drug, the geographical setting, and various social factors. For instance, heroin use in one community might manifest a distinct cultural pattern compared to heroin use in another, or even among different racial or ethnic groups within the same location.

Like any culture, drug cultures possess a shared history that is transmitted through language. Language plays a crucial role in establishing and perpetuating cultural norms, ensuring their continuation across generations. Importantly, drug cultures provide significant value to their members. While the negative health, social, psychological, and biological impacts of drug use are widely recognized, it is equally vital to acknowledge the cultural benefits that can draw individuals into these communities. Understanding these benefits adds a critical layer to our perspective on an individual's drug use, moving beyond a purely harm-reduction or pathological framework to consider the contextual advantages perceived by users.

Drug Cultures Can Provide...

Drug cultures, often envisioned as groups of individuals regularly using a specific substance, offer a range of perceived benefits that extend beyond the pharmacological effects of the drug itself. These benefits are integral to the cultural fabric and contribute to the sustained engagement of members.

One primary offering is social support. Within a drug culture, individuals find a group and a shared identity. This identity can even be celebrated, particularly for those who experience social rejection or live in societies where their primary identity is stigmatized, discriminated against, or subjected to violence. For example, studies on gay men using specific drugs have highlighted the formation of communities and social activities where individuals feel a sense of belonging and access to connection, sometimes linked to sexual experiences. This communal aspect can be a powerful draw.

Certain drugs can also serve as a status symbol within specific contexts, contrasting with the societal stigma often associated with drug use. In neighborhoods or cities where conventional avenues for economic success and social mobility are severely restricted, drug cultures can offer an alternative career path. Individuals may enter networks where they can earn money through drug sales, gain status, and forge social connections that are otherwise unavailable.

Social and cultural activities are central to drug cultures, facilitating a significant socialization process. While some drug cultures can foster antisocial behavior or avoidance of intimacy, many provide opportunities for shared experiences and communal engagement. This socialization process is particularly potent for adolescents, who are already navigating identity formation, hormonal changes, and heightened anxieties. In an age dominated by social media and constant, dopamine-driven messaging, the allure of social connections and acceptance within a drug culture, coupled with the immediate gratification of substance use, can be immense. This highlights that drug use is not solely an individual choice but is deeply embedded within larger cultural phenomena (Kurtz, 2005).

Mass Culture

Mass culture, encompassing broader societal aspects such as music, politics, and media, significantly influences drug use. There exists a reflexive relationship where drug cultures can inspire new genres of music or become deeply intertwined with existing ones. Political ideologies and media messages also play a substantial role in shaping the cultural perceptions and norms surrounding specific drugs. For instance, the widespread promotion of alcohol in society often portrays it in a highly positive light, to the extent that it is frequently not even categorized as a drug, despite its potent and potentially destructive nature. This societal separation of "alcohol" from "drugs" reflects deeply ingrained cultural ideas, often influenced by economic interests.

Drug cultures frequently manifest as subcultures, and within these, countercultures can emerge that directly oppose mainstream values. These countercultures may reject materialism, capitalism, or conventional societal norms, offering an alternative path. The attraction to such a culture can, in fact, precede the actual initiation of drug use. If an individual resonates with a philosophy that prioritizes love and connection over material possessions, or seeks to disengage from societal pressures, and finds like-minded individuals within a culture where a particular drug is commonly used and socialized, this can serve as a powerful gateway. Subsequently, individuals may become susceptible to addiction, illustrating how cultural attraction can pave the way for substance use and dependence.

(Manning, 2013; Adlaf & Smart, 1997)

Culture of Addiction

The concept of the culture of addiction positions drug use within an informal social network characterized by specific group norms. These norms, which include prescribed patterns of perceiving, thinking, feeling, and behaving, actively promote and sustain excessive substance use. This framework emphasizes that addiction is not merely an individual's struggle with a substance, but a deeply embedded cultural phenomenon that reinforces and perpetuates problematic behaviors.

The role of a drug culture in addiction extends far beyond the substance itself. It creates an environment that is highly effective in reinforcing denial. For example, in a college subculture where binge drinking is normalized and perceived as a positive aspect of social life, individuals may struggle to recognize their own problematic alcohol use because it aligns with the prevailing group behavior. When "everyone is doing it," the idea of having an addiction becomes difficult to reconcile.

Furthermore, the influence of these cultures tends to strengthen over time, making it increasingly challenging for individuals to disengage. If an individual's identity is tightly intertwined with a drug culture, leaving it can mean severing ties with friends, and potentially even family, and abandoning a familiar lifestyle. This highlights the profound gravity of breaking away from such a deeply entrenched cultural affiliation.

The culture of addiction can manifest in different forms. An "enmeshed" individual's entire identity revolves around their drug use; they might constantly talk about it, wear clothing that signifies their affiliation, and define themselves primarily by their substance of choice. A "bicultural" individual lives in two distinct worlds, maintaining a separate professional or family life while engaging in substance use in a different social context. This separation allows for a degree of denial, as the individual may believe their addiction is contained and does not impact their "other" life. Finally, "acultural" addiction exists when there is no discernible group culture surrounding the substance use.

(White, 1996)

Acultural Addicts

Acultural addicts represent a distinct category within the spectrum of substance use, characterized by their use in isolation, often obtaining drugs through legitimate channels, and maintaining a strong association with mainstream culture. This form of addiction typically involves closeted use, where the individual's substance use is hidden from their social and professional circles.

A common example of acultural addiction is observed among health professionals who misuse prescription drugs. Studies indicate that a significant percentage of health professionals engage in diversion and struggle with substance use issues. Their ability to access legitimate channels for drugs, coupled with their professional status, can facilitate isolated use and make it harder for their addiction to be detected.

Wealth can also contribute to cultural addiction by enabling isolation. An affluent individual living in relative solitude, perhaps with a spouse who is frequently absent due to work, may have the means to consume excessive amounts of alcohol or other substances without immediate external consequences. This isolation can become a significant barrier to seeking help or even recognizing the problem, as the individual may not experience the typical social or legal repercussions associated with more public forms of drug use.

Furthermore, high social status can reinforce denial. If an individual is high-functioning and maintains a successful career or social standing despite their hidden substance use, they may mentally rationalize that they cannot possibly have a problem. This strong denial, stemming from their perceived status and functional abilities, can significantly impede their path to recovery. The absence of a visible drug culture means there are fewer external cues or social networks that might challenge their denial or encourage them to seek assistance.

Language, Values, & Stories

Every culture, including drug cultures and cultures of addiction, is characterized by its unique language, values, and stories. Within drug cultures, a distinct terminology emerges, serving as a marker of legitimacy and belonging for its members. This specialized lingo can be difficult for outsiders to keep up with, as it constantly evolves with time and place. Understanding this language is crucial for practitioners seeking to connect with individuals within these cultures, though it requires continuous effort to stay current.

Storytelling plays a vital role in transmitting and reinforcing the cultural norms of drug use. These narratives often emphasize the positive aspects of drug use, highlighting experiences of status, pleasure, or successful evasion of consequences. For example, stories might recount a "fun night" or a clever way someone "got away with" using. However, within these same conversations, there can also be discussions about the need to quit or take a break. This duality reflects the internal conflict that can exist within individuals and the culture itself, where the desire to continue using coexists with an awareness of negative impacts. This can be seen in smoking culture, where individuals might declare an intention to quit by a certain age, even while deeply embedded in the cultural practices of smoking.

The values within drug cultures often prioritize immediate gratification, risk-taking, and a rejection of mainstream societal norms. The shared stories contribute to a collective identity, shaping how members perceive themselves and their relationship to the drug and the wider world. These narratives can glorify certain behaviors, normalize excessive use, and create a shared understanding of the drug's role in their lives. The emphasis on shared experiences and collective narratives reinforces the cultural bond, making it a powerful force that can both draw individuals in and make it challenging for them to leave.

Material Culture

Material culture, the tangible aspects of a way of life, is a significant component of drug cultures. This includes paraphernalia directly associated with drug use, such as pipes, syringes, or rolling papers. These objects are not merely tools; they often carry symbolic meaning and contribute to the rituals and identity of the culture.

Appearance is another facet of material culture that can vary within drug cultures. While some individuals may exhibit a neglected appearance due to the impact of their drug use, others might maintain a meticulous facade as part of their denial or to blend into mainstream society, particularly in cases of acultural addiction. This duality in appearance can reflect the diverse ways individuals navigate their addiction within a cultural context.

Music frequently plays a central role, with genres and specific songs celebrating drug use. This music can become a powerful trigger in recovery, evoking memories and cravings. Art and literature also contribute to the material culture, with addiction memoirs and other creative expressions sometimes glorifying drug use, further embedding it within a cultural narrative.

Diet, though less commonly discussed in this context, can also be heavily affected. Drug use can suppress appetite, lead to poor nutritional choices, and generally diminish self-care practices related to health and well-being. The lack of attention to diet within some drug cultures can contribute to the overall physical decline associated with prolonged substance abuse. These material elements collectively reinforce the cultural norms and practices surrounding drug use, making it a pervasive and deeply integrated aspect of individuals' lives.

Rituals & Activities

Rituals and activities form the behavioral core of drug cultures, dictating how and where drugs are used, and how their consumption is integrated into social life. An intriguing phenomenon within some drug cultures is the need to be taught how to enjoy a drug. For instance, an individual's first experience with alcohol might involve nausea and a severe hangover, making it an unpleasant experience. The culture then socializes the individual to perceive the positive aspects of drinking, to learn that the pleasurable effects outweigh the negative consequences, and to develop a tolerance that allows for enjoyment. Similarly, initial marijuana use can induce dizziness, disorientation, or anxiety. The culture teaches individuals how to navigate these initial unpleasant sensations and to appreciate the desired "high," a process that can take time and repeated exposure.

Social activities are often centered around drug use, leading to a preoccupation with obtaining and consuming the substance. This preoccupation can extend to "hustling" and making money, as addiction can be incredibly expensive. The constant pursuit of funds to acquire drugs becomes a significant ritual and activity within the culture.

Furthermore, drug cultures often involve actions designed to avoid consequences. Members learn strategies to evade detection, such as how to pass a drug test or how to conceal their use. These learned behaviors reinforce the culture of secrecy and denial that can surround addiction.

Engagement in drug culture rituals and activities can also influence an individual's personality. Traits such as paranoia, depression, narcissism, risk-taking, anti-authoritarianism, intimacy issues, avoidance of close relationships, and manipulative tendencies can emerge or be exacerbated through prolonged involvement in these cultures. While these traits may be deeply ingrained, the sociological perspective suggests that they can, in many cases, be decoupled from the individual's core personality and addressed through therapeutic interventions, revealing a different self beneath the layers of addiction-influenced behaviors.

Social Roles

Within the culture of addiction, a diverse array of social roles emerges, each contributing to the perpetuation and dynamics of the group. These roles, as described by William White, offer a sociological and anthropological lens through which to understand the intricate cultural dynamics. While a comprehensive list is extensive, examining a few key roles highlights their significance and potential transference to recovery cultures.

The "High Priests" are individuals who passionately advocate for and are highly public about the use of certain drugs. They may amass followers and disseminate messages that encourage substance use, often with negative consequences due to their public visibility and excessive consumption, increasing their risk of overdose. The "Storytellers" play a crucial role in transmitting the culture by recounting narratives that glorify drug use and paint a vivid picture of the culture, thereby reinforcing its positive associations. "Ambassadors" are highly connected individuals who are aware of various social groups and events, serving as conduits of information and often leveraging this knowledge for status within the culture.

Other roles include "The Dealers," who facilitate access to substances; "The Medicine Men and Midwives," who may offer advice or remedies related to drug use or its effects; "The Jailhouse Lawyers," who navigate legal systems; "The Gangsters" and "The Nonaddicted Hustlers," involved in illicit activities for financial gain; "The Addict with Money and Fame," whose status may mask their addiction; "The Working Class Addicts" and "The Weekend Players," representing different patterns of use; "The Pledges," new or aspiring members; "The Crazies," whose behavior may be erratic; "The Marks," who are exploited; "The Man," representing authority; "The Snitches," who betray trust; "The Protectors," who shield others; "The Pseudo Junkies," who mimic addiction without full dependence; "The Cultural Rejects," who find belonging in the drug culture after being marginalized elsewhere; and "The Profiteers," who benefit financially from the drug trade.

These social roles provide identity and, importantly, can involve transferable skills. This concept becomes particularly relevant when considering the transition to recovery, as many of these roles mirror those found in recovery culture, offering a potential asset for individuals seeking to change their lives.

Culture of Recovery

The culture of recovery, mirroring the structure of drug cultures, is defined as an informal social network where group norms reinforce sobriety and long-term recovery from addiction. Just as drug cultures, through their inherent nature and offerings, reinforce drug use, recovery cultures are designed to reinforce abstinence and healthy living. The transition from a culture of addiction to a culture of recovery represents a significant undertaking, often requiring individuals to sever deep-seated bonds and alter their entire lifestyle. For instance, if a workplace culture normalizes cocaine use for productivity or socialization, an individual seeking recovery faces the immense challenge of maintaining their employment within that same environment while simultaneously breaking free from the social connections and behaviors associated with the drug. This highlights the profound gravity of separating from one culture and embracing another, especially when the existing environment remains unchanged.

(White, 1996)

A Cultural Transition

William White's concept of "cultural conversion," which can be more broadly termed a "cultural transition," describes the profound shift individuals undergo in recovery. This process involves exploring alternative ways to meet the needs previously satisfied by drug culture. For example, if cocaine provided energy, talkativeness, and a sense of connection, recovery culture must offer avenues for vulnerability, confidence, and genuine connection without substance use.

This transition also necessitates exploring the intricate connections between drug culture and an individual's interests, goals, and potential false beliefs. It involves a deconstruction of how drug culture may have reshaped personal aspirations. For instance, a college student with pre-med ambitions might become immersed in a drug culture that promotes anti-establishment philosophies, leading them to abandon their educational goals. In recovery, this individual can revisit why they initially pursued pre-med, questioning whether their current beliefs about higher education were genuinely their own or a product of the drug culture's influence. Similarly, a restaurant worker in an alcohol-centric culture might have discussed aspirations for healthier eating or exercise while drinking. Recovery provides an opportunity to recognize how the social group might have impeded these desired changes.

Integrating spirituality as a framework for alternative ideas is another crucial aspect of this cultural transition. For individuals drawn to anti-materialistic philosophies within drug culture, a spiritual perspective can offer a resonant and constructive pathway. Spirituality often provides an alternative worldview that aligns with the values of recovery, such as self-reflection, community, and purpose beyond material possessions.

Ultimately, recovery involves developing a new cultural identity. This new identity is not merely the absence of drug use but a proactive embrace of new norms, values, and social roles that support sobriety and personal growth. It is a fundamental reshaping of self within a supportive cultural context.

Recovery Cultures

Recovery cultures, much like drug cultures, possess distinct norms and expectations that are reinforced by the group. These cultures provide vital networks and peer support, fostering a sense of belonging and shared purpose. Socialization within recovery cultures involves learning new ways of acting and speaking, adopting language and behaviors that align with sobriety and personal growth.

Recovery cultures manifest in various forms, including formal treatment programs, self-help groups, and the widely recognized 12-step programs. Each of these diverse recovery cultures offers a unique pathway to sobriety, though they all share the common goal of supporting long-term recovery.

It is important to acknowledge that individuals often reside in multiple cultures simultaneously. On this note, "cultural recovery" refers to recovery programs that explicitly integrate other cultural memberships. For example, a program might incorporate the spiritual or cultural frameworks and verbiage of an indigenous population, creating a more resonant and effective pathway to recovery for individuals from that background. This integration can be particularly beneficial, as it addresses the potential disconnect between an individual's home culture or family culture and the recovery process, fostering a deeper sense of connection and belonging.

History

The history of recovery and treatment for substance use disorders is a fascinating and complex narrative, spanning centuries of evolving understanding and approaches. While the precise origins of individuals overcoming addiction are lost to antiquity, more recent historical developments offer valuable insights into the emergence of formal recovery movements and treatment modalities.

The early 19th century witnessed a significant surge in alcohol consumption, particularly from the late 1700s to the early 1800s. This societal shift, influenced by economic factors and increased availability of alcohol, spurred the rise of the Temperance Movement in 1825. This movement aimed to curb alcohol consumption through moral persuasion and social pressure.

A notable offshoot was the Washingtonian temperance movement, which began in 1840. This movement bore striking similarities to later social support systems like Alcoholics Anonymous. It comprised groups of individuals who, having struggled with heavy drinking, sought to achieve sobriety through mutual peer support. Their meetings involved sharing experiences, a practice that would become central to subsequent recovery programs. The Washingtonian movement gained remarkable momentum, spreading rapidly across communities. However, despite its initial success, it largely dissipated after approximately five years, highlighting the challenges of sustaining such movements without formal organizational structures.

Following the decline of the Washingtonian movement, treatment "asylums" began to emerge around 1845. These institutions served as places where individuals could seek refuge and sobriety. By 1877, the "Journal of Inebriety" was established, marking a significant step towards the medicalization of addiction, framing it as a health condition rather than solely a moral failing. The 1890s saw the emergence of dedicated treatment hospitals and the closure of many asylums, reflecting a shift in the approach to mental health and addiction.

In 1906, the Emmanuel movement introduced a remarkably holistic approach to recovery. This program emphasized psychology, spirituality, relaxation techniques, and the importance of social services and lay therapists. It fostered an environment where multiple dimensions of an individual's well-being were nurtured, a comprehensive approach that, in some ways, predated and even surpassed certain modern recovery models in its integrated nature. Unlike some contemporary programs, it actively connected individuals with foundational social services, recognizing their importance for sustained recovery.

The Oxford Group, formed in 1908, played a pivotal role in shaping future recovery movements. Its principles, including self-survey, confession, restitution, and service, directly influenced the foundational tenets of Alcoholics Anonymous.

A significant disruption to the burgeoning treatment landscape occurred with the advent of Prohibition in 1919. This nationwide ban on alcohol severely curtailed access to formal treatment, as the prevailing belief was that the problem would simply disappear once alcohol was illegal. However, Prohibition proved largely ineffective and was repealed in 1933.

Just two years later, in 1935, Alcoholics Anonymous (AA) was founded. Drawing inspiration from the Oxford Group and the Washingtonian movement, AA revolutionized addiction recovery by establishing a peer-led, self-help model that emphasized spiritual principles, mutual support, and a structured pathway to sobriety. Its enduring legacy continues to shape the landscape of recovery cultures worldwide.

AA and 12-Step Culture

Alcoholics Anonymous (AA) and its numerous 12-step offshoots represent a powerful and pervasive recovery culture, offering a structured pathway to sobriety for individuals struggling with various addictions. Understanding this culture is paramount for anyone working with or affected by it. While AA is designed to be non-hierarchical and self-governing, its cultural dynamics are incredibly potent and well-defined.

At the core of 12-step culture is the recognition of denial, powerlessness, selfishness, and a "loss of sanity" due to addiction. The first step, admitting powerlessness over alcohol or the specific substance, is often a monumental leap for individuals, given the pervasive nature of denial, frequently reinforced by drug cultures. Accepting that one cannot control their substance use and acknowledging its destructive impact on their lives and relationships is a foundational principle.

The culture emphasizes that guilt and resentment are significant fuels for addiction. Through a process of self-inventory and confession, individuals are encouraged to examine their past actions, identify their role in harming others, and make amends. This involves ongoing restitution and a commitment to service, which is seen as a vital component of sustained recovery. Recovery in 12-step culture is not merely the cessation of substance use; it is embraced as a comprehensive lifestyle, a fundamental reshaping of one's identity and daily practices. This cultural immersion provides a framework for living sober, offering a new set of norms, values, and behaviors to replace those associated with active addiction.

Language, Values, & Stories

The 12-step culture, like any robust cultural system, possesses its own distinctive language, values, and stories that reinforce its principles and guide its members. Recovery literature, particularly the "Big Book" of Alcoholics Anonymous, serves as a foundational text, transmitting core concepts and narratives.

Slogans are a pervasive and powerful element of 12-step language. Phrases like "easy does it" and "one day at a time" are not merely catchy sayings; they are practical tools designed to help individuals navigate the challenges of early sobriety. The "one day at a time" philosophy, in particular, mirrors a certain aspect of addiction culture where the focus is often on immediate gratification, but it reorients that immediate focus towards sobriety. "Keeping things simple" is another slogan that encourages a straightforward approach to recovery, avoiding overcomplication. These slogans become internalized mantras, guiding daily decisions and offering comfort during difficult moments.

The concept of "character defects" is central to the 12-step lexicon, referring to personality traits or behaviors that may have contributed to or been exacerbated by substance use. The culture encourages individuals to identify these defects and work towards their "opposites," such as replacing judgment with acceptance. Conversely, "assets" are recognized as positive qualities that can be leveraged in recovery, fostering a balanced self-assessment.

A profound "transcendent focus" characterizes 12-step culture, emphasizing a spiritual dimension. This often involves experiencing "moments of clarity" or "awakening," signifying a profound shift in self-perception and a deeper connection to a higher power (however conceived). The idea of "surrender" is paramount, implying a letting go of self-will and embracing faith, acceptance, tolerance, patience, honesty, openness, and humility. These values are actively promoted and practiced within the culture, often standing in stark contrast to the values of mainstream society, which may emphasize competition, status, and individual control. This counter-cultural aspect can resonate deeply with individuals transitioning from drug cultures, offering an alternative framework for living.

Material Culture

The material culture of recovery, particularly within 12-step programs, provides tangible symbols and practices that reinforce sobriety and a new way of life. Objects play a significant role, such as recovery coins or "chips" that mark milestones of sobriety. These coins serve as physical reminders of commitment and progress, offering a sense of accomplishment and belonging. Talismans, personal objects imbued with symbolic meaning, and recovery-focused books are also common elements.

Dress and appearance can also reflect an individual's engagement with recovery culture. This might include wearing clothing with recovery messages, or a renewed focus on self-care and hygiene as part of a healthier lifestyle. Tattoos, which may have been acquired during active addiction, might be altered or covered to signify a break from the past.

Music continues to be a powerful medium, but in recovery, the focus shifts. Individuals may examine song lyrics more critically, replacing words or finding new music that resonates with their sober identity. Art is often utilized as a therapeutic outlet, providing a means for self-expression and processing emotions without substance use.

Food and diet, though not always explicitly central to 12-step programs, are implicitly linked to recovery through the broader concept of self-care. While slogans like "keep candy handy" might suggest a simple substitution for the sugar in alcohol, a deeper understanding reveals the profound connection between nutrition, brain health, and sustained recovery. Exploring the mind-body-behavior connection through diet can be a vital, though often overlooked, aspect of healing. These material elements collectively contribute to the formation of a new identity and lifestyle that supports long-term sobriety.

Rituals & Activities

Rituals and activities are the bedrock of recovery culture, providing structured pathways for maintaining sobriety and fostering personal growth. Reading recovery literature, such as the "Big Book" or other approved texts, is a fundamental ritual, offering guidance, shared experiences, and reinforcement of core principles.

Self-care, particularly through exercise, is increasingly recognized as a vital activity in recovery, promoting physical and mental well-being. Prayer and meditation are integral components of 12-step programs, fostering a spiritual connection and providing a means for introspection and emotional regulation.

Meetings are central to recovery culture, offering a safe space for individuals to share their experiences, strengths, and hopes. Sharing within these meetings, engaging in phone calls with fellow members, and consistently using recovery slogans reinforce the cultural norms and provide immediate support. The practice of taking inventories, making amends for past harms, engaging in service to others, and participating in mentoring relationships (sponsor-sponsee dynamics) are all crucial rituals that facilitate personal accountability and growth.

Socializing with friends and family, often within the context of safe havens and avoiding trigger places, is a key activity in rebuilding healthy relationships. The formation of new social groups and the adoption of a new persona are natural outcomes of this cultural transition. By comparing these rituals and activities to those found in drug cultures, it becomes evident how recovery cultures effectively meet the fundamental human needs for connection, identity, and purpose, which were previously sought through substance use. The similarities in the group aspect, the shared culture, and the propagated beliefs and values make the transition to recovery culture a more comprehensible and achievable journey.

Social Roles

Like the culture of addiction, the culture of recovery features a rich tapestry of social roles that contribute to its functionality and support its members. The presence of these roles highlights a crucial asset in the recovery journey: the potential for transferable skills from addiction culture to recovery culture.

For instance, the "High Priests" in addiction culture, who were charismatic leaders passionately advocating for drug use, can transform into powerful advocates within recovery. Their leadership qualities, even with their past negative associations, can be channeled into promoting sobriety and guiding others. Similarly, the "Storytellers" from addiction culture, known for their vivid narratives of drug use, can become compelling speakers in recovery meetings. Their ability to "paint the picture" of their past addiction and their journey to recovery serves to transmit the culture of recovery to newcomers, offering hope and relatable experiences.

"Ambassadors," who were once adept at navigating various social groups and gathering information within drug culture, can become invaluable resources in recovery. Their inquisitive nature and strong listening skills can be repurposed to connect individuals to meetings, resources, and other members, effectively serving as navigators within the recovery community. Their ability to know "what's going on with people" can be a tool for support and outreach.

Other roles within recovery culture include "The Elders," seasoned members who offer wisdom and guidance; "The Comedians," who use humor to lighten difficult topics; "The Professors," who share knowledge and insights; "The Professionals," who integrate their recovery into their careers; "The Two-Hatters," who balance their professional and recovery identities; "The Bleeding Deacons," who are open about their struggles to help others; "The Medicine Men and Midwives," who offer healing and support; "The Chronically Failing Sinners," who persist despite setbacks; "The Organizers," who facilitate meetings and events; "The Self-Cured," who found recovery outside traditional programs; "The Mentors," who guide newer members; "The Fundamentalists," who adhere strictly to program principles; "The Confused Protectors," who struggle with boundaries; "The Saboteurs," who may undermine others' recovery; "The Pigeons," who are easily influenced; "The Pilgrims," who are on a spiritual journey; and those dealing with "Pseudo-Addiction."

The key takeaway is that the skills and characteristics developed within the social roles of addiction culture are not necessarily lost or entirely negative. With awareness and guidance, these attributes can be reframed and utilized as assets in the recovery process, contributing to a new, healthier identity and a supportive community. Observing and discussing these relatable assets can be a valuable tool in therapeutic settings and in the broader recovery movement.

Practice Applications

Bringing together the insights on drug culture and recovery culture offers significant practical applications for practitioners across various fields, including social work, counseling, psychology, and healthcare. The foundational understanding that cultural influences profoundly shape an individual's life, even if not immediately apparent, is the crucial starting point. This contrasts with a narrow focus on individual pathology and encourages a broader, more empathetic perspective.

Understanding drug and addiction culture, including the concept of the acultural addict, is paramount. This knowledge can significantly aid in establishing and strengthening the therapeutic alliance, the connection between the practitioner and the person served. Just as cultural competency in other areas enhances rapport and trust, an awareness of the cultural context of substance use can foster a more effective therapeutic relationship, leading to better treatment adherence and outcomes. Practitioners do not need to be experts in every subculture, but a general awareness of cultural influences allows for informed inquiry and a more nuanced approach to care.

This understanding also provides invaluable insight for assessment. Beyond asking about the immediate effects of drug use, practitioners can inquire about the perceived benefits derived from being part of a group or culture associated with substance use. This opens up a new set of assessment tools, enabling the design of more tailored programs and interventions that address the underlying social and emotional needs fulfilled by drug culture.

Furthermore, it is critical for practitioners to recognize that leaving a drug culture can be even more challenging than ending drug use itself for some individuals. While the self-destructive nature of drug use may create a strong desire to quit the substance, severing ties with a deeply ingrained lifestyle, social network, and even one's home environment presents an entirely different set of obstacles. This awareness allows practitioners to anticipate and address the profound sense of loss and disruption that individuals may experience when transitioning out of a drug culture, and to integrate strategies that support the rebuilding of a new, sober life.

Concluding Thoughts

The exploration of drug culture and the culture of recovery underscores several fundamental concluding thoughts that are critical for a holistic understanding of substance use disorder.

First, social and environmental factors matter profoundly. While this may seem intuitively obvious, the full extent to which one's social environment, sense of belonging, identity, and safety impact psychological and biological well-being, and even genetic expression, is often underestimated. Research demonstrates that social isolation, for instance, is a more powerful predictor of premature mortality than excessive smoking, chronic alcohol use, or a sedentary lifestyle, even when controlling for other health-related factors. This highlights the transformative power of moving from isolation to connection, emphasizing that social integration is not merely a desirable outcome but a vital determinant of health and longevity. The deep physiological and neurological impacts of the social environment warrant further exploration, as they can fundamentally shift one's perspective on addiction.

Second, addiction extends far beyond the individual; it is inherently a social problem. The escalating opioid crisis, the rise in drug poisonings, and the increase in suicide rates cannot be solely attributed to individual factors. These societal challenges are deeply rooted in how individuals are treated within society, the messages they receive, the economic conditions of their communities, and the systemic failures to provide basic needs. Drug cultures, in this context, can paradoxically serve as safe havens, offering a sense of belonging and identity when other societal structures fail to do so.

Third, identities are significantly shaped by culture. An individual's personality is not solely an innate trait; it is profoundly influenced by the cultural contexts in which they develop and participate. Recognizing that addiction goes beyond individual choice, and that adverse childhood experiences, for example, can alter brain function and limit life options, fosters a more compassionate and effective approach. When working with individuals who appear to make self-destructive or "unintelligent" decisions, adopting the perspective that they are often doing what is within their power to cope with their circumstances can alleviate frustration and resentment for providers. This reframing can enhance the willingness to engage with individuals who may struggle with treatment adherence or service utilization.

Finally, the needs fulfilled by drug culture can indeed be addressed in recovery culture. By comparing the elements of drug culture—its propagated beliefs, values, material culture, identity ties, and group aspects—with those found in recovery culture, it becomes evident that numerous similarities exist. This parallel structure suggests that recovery can be framed as a transition to a new, healthier lifestyle that still fulfills fundamental human needs for connection, identity, and purpose. Recognizing and leveraging these similarities can be a powerful tool for practitioners, helping individuals to see recovery not as a deprivation, but as an alternative, fulfilling cultural pathway.

References

Select references are listed here. The full reference list is included in the course handout.

Adlaf, E. M., & Smart, R. G. (1997). The cultural context of adolescent drug use: A review of the literature. Addiction Research & Theory, 5(2), 177-195.

Kurtz, E. (2005). The spirituality of imperfection: Storytelling and the search for meaning. Bantam.

Manning, P. (2013). Drugs and popular culture in the age of rock 'n' roll. Routledge.

White, W. L. (1996). Pathways from the culture of addiction to the culture of recovery. Hazelden.

Editor’s note: This text-based course is an edited transcript of the webinar, Working with Transgender and Gender Diverse Youth: Navigating the Current Political Climate, Clinical Practice Guidelines, and Ethical Considerations, presented by Giselle Levin, PsyD.

Learning Outcomes

After this course, participants will be able to:

• Describe current mental health challenges facing transgender and gender-diverse youth.
• Identify standards and clinical practice guidelines for provision of gender-affirming care of youth.
• Apply clinical interventions to support transgender and gender-diverse youth coping with minority stress and other mental health challenges.

Limitations/Risks

• This presentation presents the fundamentals of working with trans and gender-diverse youth. Further training, supervision, and/or consultation may be required before working with specific patients. 
• Information in the presentation is generalized and may not apply to specific patients. Refer or consult as needed.
• Ethical and legal standards may differ from state to state. Ensure that you are familiar with the laws and ethics specific to your state. 
• Individual and cultural considerations should be explored prior to pursuing treatment and interventions.

Introduction

Today, we will explore how mental health professionals like you can support transgender and gender-diverse youth and their families in your practice. We will focus on the impact of minority stress, discussing its significance and associated mental health challenges. As a fundamental course, we'll introduce the standards of care, though we will not delve deeply into complex topics.

Assessing gender-diverse youth for readiness to begin puberty blockers, hormones, or surgeries requires a nuanced approach. Such medical gender-affirming care demands additional training, supervision, and consultation. You may encounter patients with complex needs that necessitate specialized attention. In these cases, always refer or consult based on your training level and comfort with the patient's specific situation.

We'll also cover some general information useful when dealing with particular cases. Understanding ethical and legal standards is crucial, which vary significantly from state to state. I will show a detailed map highlighting the various pieces of legislation proposed and passed across different states. Being aware of the laws in your state is essential, as is understanding the ethical codes specific to your professional field. For instance, as a psychologist, my guidelines might differ from those for Licensed Marriage and Family Therapists (LMFTs) or social workers. Lastly, we must consider individual and cultural factors before pursuing treatment or interventions. These preliminary considerations are vital in providing effective and sensitive care to your patients.

The Political Climate: Events, Legislation, and Articles

Let's examine the current political climate, focusing on recent events, legislation, and related articles. We'll start with anti-transgender bills in 2024. Remarkably, even though it's only April of 2024, there have already been 539 bills proposed across 41 states this year. This widespread legislative activity has affected nearly every state in the U.S. Of these bills, 21 have passed, 92 have failed, and the majority, 426, remain active. This volume of legislation underscores the significant attention and contention surrounding this issue.

What exactly do these bills entail? These bills target:

• Re-definition of sex
• Curriculum censorship
• School facilities bans (bathrooms, lockers)
• School sports bans
• Forced outing in schools

The redefinition of sex often stipulates sex as strictly binary—male or female—and identical to the sex assigned at birth. This conflation of sex and gender precludes any later changes in gender identity if it doesn't match the sex assigned at birth.

Another significant area is curriculum censorship. This includes bills that prevent discussions about LGBTQ+ individuals, particularly transgender and gender-diverse topics, within schools. It restricts teachers from using books with non-binary or transgender characters and limits educational resources and opportunities. Such bills also aim to censor or ban LGBTQ+ groups in schools and impose facility bans that restrict students from accessing certain facilities, like bathrooms, that do not align with their gender assigned at birth. 

For example, a transgender girl who fully presents as female would be compelled to use the boys’ bathroom or locker room. School sports bans are also prevalent, prohibiting transgender students from joining teams that align with their gender identity rather than their assigned sex at birth.

Forced outing is another concerning issue. This practice requires that transgender students be outed at school, making their transgender status known to teachers and peers, which can lead to bullying and create a hostile environment.

Healthcare restrictions are also widespread. These include age limits on accessing gender-affirming care and could even carry criminal penalties for providers who offer such care to transgender youth. Interestingly, these restrictions often exempt similar treatments for cisgender youth or mandatory treatments for intersex infants.

Speaking of intersex individuals—those whose biological characteristics do not fit typical binary notions of male or female bodies—it’s estimated that approximately 1.7% of the population is intersex. This might involve chromosomal differences or ambiguous genitalia. Many intersex infants undergo surgery without their consent, yet such procedures are generally not subject to the same restrictions as gender-affirming surgeries for older youth.

Additionally, there are prison restrictions that disproportionately affect transgender individuals in incarceration, often denying them access to essential gender-affirming treatments. Funding restrictions also play a role, blocking programs like Medicaid from covering necessary treatments for transgender individuals.

Religious exemptions are another barrier, allowing healthcare providers and others in the community to deny care or services to LGBTQ+ individuals based on religious beliefs. Lastly, there are significant hurdles regarding accurate IDs. Restrictive bills limit the ability to update gender information on official documents like birth certificates and driver's licenses, which can lead to discrimination and violence, as well as practical challenges in employment, housing, and travel.

In addition to the types of bills previously discussed, there are other anti-LGBTQ+ legislative actions that don't necessarily fit neatly into those categories. These include bans on marriage equality and bills that preempt or override local non-discrimination protections, stripping back established rights and safeguards for LGBTQ+ individuals.

Bills Passed in 2024

AL SB129: “Each public institution of higher education shall ensure that every multiple occupancy restroom be designated for use by individuals based on their biological sex.”

In higher education, policies now mandate that individuals use restrooms based on their biological sex, not their gender, gender identity, or presentation. This requirement overlooks the complexities of gender expression and identity.

ID H0421: “In human beings, there are two, and only two, sexes: male and female; (2) Every individual is either male or female; (3) An individual's sex can be observed or clinically verified at or before birth”

This is scientifically incorrect. As previously mentioned, an estimated 1.7% of people are intersex, meaning they possess sex traits that do not conform to the traditional binary. For example, someone with androgen insensitivity syndrome, a common intersex condition, is genetically male with XY chromosomes but is resistant to male hormones like testosterone. Consequently, they do not develop male characteristics and typically appear female at birth, often being designated as female despite lacking internal female reproductive organs and being infertile.

Another intersex condition, congenital adrenal hyperplasia, occurs in individuals with XX chromosomes who produce high levels of androgens. This can lead to ambiguous genitalia, where external genitalia may appear male, yet internal genitalia include a uterus. Therefore, the sex of someone with congenital adrenal hyperplasia cannot be definitively observed or clinically verified at birth.

These examples illustrate that such legislation is not grounded in science and is, in fact, scientifically inaccurate. It can be especially harmful not only to transgender individuals but also to those who are intersex.

WI AB377: “The three designations are 1) males, 2) females, and 3) males and females. The bill defines “sex” as the sex determined at birth by a physician and reflected on the birth certificate. The bill also requires an educational institution to prohibit a male pupil from participating on an athletic team or in an athletic sport designated for females. Finally, the bill requires the educational institution to notify pupils and parents if an educational institution intends to change a designation for an athletic team or sport.”       VETOED

This bill was vetoed, but it aimed to define sex strictly as male and female, the only designations deemed valid, a scientifically incorrect concept. Additionally, it stipulated that these designations be determined at birth. Under this bill, a male pupil—including a transgender girl—would not be allowed to participate on an athletic team or in a sport designated for females. Furthermore, the bill mandated that educational institutions notify students and parents if a transgender child was to join a sports team that aligned with their gender identity.

ID H0455: “Requiring students to share restrooms and changing facilities with members of the opposite biological sex generates potential embarrassment, shame, and psychological injury to students, as well as increasing the likelihood of sexual assault, molestation, rape, voyeurism, and exhibitionism; every public school restroom or changing facility accessible by multiple persons at the same time must be: (a) Designated for use by male persons only or female persons only; and (b) Used only by members of that sex.”

You can see that many of these rules deeply affect students, which is particularly concerning given that schools are already challenging environments for youth. Under these regulations, students would not be able to use restrooms that align with their gender identity. Interestingly, the rationale provided states that allowing students to share restrooms and changing facilities could lead to potential embarrassment, shame, and psychological injury. However, this concern appears to focus solely on cisgender students. The statement further suggests that this mixing increases the likelihood of sexual assault, molestation, rape, voyeurism, and exhibitionism.

Yet, there is no research supporting the claim that transgender individuals using bathrooms that align with their gender identity are more likely to perpetrate any form of sexual misconduct in those settings. Thus, these assertions are not backed by empirical evidence. Moreover, the policy mandates that public school restrooms and changing facilities, like locker rooms, be designated strictly for male or female use based on the sex assigned at birth.

WY SF0099: “No physician or health care provider shall: [...] Provide, administer, prescribe or dispense [...] prescription drugs that induce [...] puberty suppression or blocking prescription drugs to stop or delay normal puberty; [...] Supraphysiologic doses of testosterone to females [...] Supraphysiologic doses of estrogen to males.”

Here, we examine another bill that was passed, which prohibits physicians and healthcare providers from offering medical gender-affirming care to youth. This includes prescribing or dispensing drugs that induce, block, or delay puberty.

We'll discuss puberty blockers in more detail shortly. These medications are completely reversible and provide transgender youth with additional time to explore their gender identity and consider their options before making any irreversible decisions. Importantly, puberty blockers also spare them from undergoing puberty, which might be dysphoric and distressing. Once these blockers are discontinued, the individual will experience their natural puberty.

The bill also addresses testosterone and estrogen, which are used in hormone therapy. We will delve into the distinctions between puberty blockers and hormone therapy later. While the effects of hormone therapy are partially reversible, some aspects are irreversible. This bill bans both treatments, impacting the ability of transgender youth to receive care that could significantly ease their gender dysphoria.

ID S1352: “No person engaged in the practice of professional counseling or marriage and family therapy in the state of Idaho shall be required to provide counseling to or facilitate the counseling of a client in support of goals, outcomes, or behaviors that conflict with the sincerely held religious, moral, or ethical principles of the counselor or therapist.”

We're seeing that therapists who do not support transgender youth are not required to provide services, which, in a way, aligns with ethical obligations to refer patients when there is significant negative bias. Ethically, it is crucial that patients are treated by professionals who can support them without prejudice.

However, the situation is nuanced. While it is understandable that a transgender youth would not benefit from working with a therapist who harbors strong anti-trans sentiments, the legislation also allows therapists to refuse to facilitate counseling that supports the client's goals if these goals conflict with the therapist's moral principles. This aspect of the law can lead to a lack of support for transgender youth, as it permits professionals to decline to provide essential therapeutic services based on personal beliefs, potentially leaving vulnerable clients without necessary care.

I must emphasize that the ramifications of these bills extend beyond transgender individuals, affecting cisgender people as well. This is particularly evident in policies like bathroom bans or facility restrictions.

Consider, for instance, the impact on intersex individuals, who make up an estimated 1.7% of the population and do not fit neatly into the binary categories of male or female. They are directly affected by such legislation. But the implications also reach cisgender individuals. For example, women with polycystic ovarian syndrome (PCOS), a condition that can cause facial hair growth, may face discrimination in female restrooms despite being cisgender.

Moreover, societal assumptions about gender appearance can lead to accusations and challenges for cisgender individuals as well. Online and in public spaces, cisgender women and men are sometimes mistakenly identified as transgender, leading to harassment and discrimination. This can occur even with individuals who exhibit traditionally feminine or masculine traits—demonstrating that appearance alone is not a reliable indicator of someone's gender identity.

These legislative measures also affect children and youth, who may be subjected to similar forms of discrimination and misunderstanding. The scope of harm from such bills is wide, impacting not only those who are transgender but also many who are not, including those with certain medical conditions and the broader cisgender population.

Tracking Anti-Trans Legislation 

If you're interested in staying informed about anti-trans legislation, several excellent resources are available. "Erin In The Morning" offers a comprehensive Anti-Trans Legislative Risk Assessment Map, which details the status of proposed and passed bills in each state. This map is particularly useful for understanding the legislative risks and includes separate sections for adults and youth. Initially, much of this legislation targeted youth, but there is now also a significant amount aimed at adults.

Additionally, the ACLU is tracking 484 anti-LGBT bills. Their website provides updates on their progress, whether they have just been proposed or have already been passed. It’s a valuable resource for those looking to understand the broader scope of legislation affecting the LGBTQ+ community.

There is also a trans legislation tracker available online. This tool is specifically designed to follow legislation that directly impacts transgender individuals. Using these resources can provide a clearer picture of the legislative landscape and help you stay informed about changes that might affect your community.

In The News

Recently, there has been a noticeable increase in media coverage concerning gender-affirming care, particularly for youth. A prominent New York Times article raised concerns about the adequacy of mental health assessments for youth receiving such care. It suggested that co-occurring mental health issues were not adequately addressed, leading some individuals to ultimately detransition or express regret.

The World Professional Association for Transgender Health (WPATH), a key global organization in transgender healthcare similar to the American Psychological Association (APA), provides evidence-based standards of care. WPATH's latest manual, the Standards of Care 8, is accessible online at no cost and extensively cites the supporting research. WPATH also maintains a confidential forum for medical and mental health experts to discuss complex cases. Unfortunately, this forum was recently compromised by anti-trans activists, resulting in the unauthorized release and misrepresentation of confidential information in what became known as the "WPATH Files." 

Erin In The Morning responded with a detailed rebuttal, highlighting the misinterpretations and distortions of the leaked information, which seemed designed to fuel anti-trans rhetoric. This incident is just one example of the challenges facing medical and mental health providers working with transgender individuals, particularly youth. There have been cases of individuals posing as patients to expose providers, a form of healthcare fraud that adds to the already tense environment.

There are numerous anti-trans articles circulating. We'll discuss further how this affects transgender youth and explore ways you, as a provider, can take a supportive stance. It's crucial to understand that transgender healthcare, particularly for trans youth, is currently at the center of intense political controversy. This group has been singled out as a focal point for debate and conflict. Consequently, there is a significant amount of anti-trans rhetoric specifically targeting this vulnerable population. As healthcare providers, recognizing this context is essential for effectively supporting and advocating for transgender youth.

Trans and Gender-Diverse (TGD) Youth

Let's shift our focus to understanding trans and gender-diverse youth. First, it's important to clarify terminology. We often use the terms "trans and gender-diverse" or "trans and gender-expansive" because not all youth under this umbrella identify strictly as transgender. Additionally, some children who identify as gender-diverse in their youth may not retain these identities into adulthood. Gender diversity can be fluid and subject to change, which we'll explore further.

To provide some context on the broader spectrum of LGBT identification, let’s consider recent data. According to a Gallup Poll, which has been tracking LGBT identification since 2012, with the latest poll conducted in 2024, there are notable generational differences in how people identify. Among Boomers, only 5% identify as part of the LGBT community, compared to 10% of Millennials and a significant 25% of Gen Z—reflecting a substantial generational shift.

Specifically focusing on transgender identification, the numbers are smaller but still indicative of a generational change: 0.2% of Boomers, 1.1% of Millennials, and 2.8% of Gen Z identify as transgender. Most of the LGBT Gen Zers are bisexual, with about 15% identifying as such, which is a stark contrast to those identifying as gay or lesbian. Other identities within the LGBT spectrum, including transgender, represent smaller percentages but are crucial for understanding the full diversity within these communities.

Figure 1. Graph showing the percentage of people identifying as LGBTQ+.

Since the initiation of the Gallup Poll in 2012, which tracks LGBT identification among those aged 18 and older, there has been a noticeable increase in the percentage of individuals identifying as LGBT. Figure 1  provides a visual display of this information. In 2012, approximately 3.5% of the population identified as LGBT, a figure that rose to 5.6% four years ago and stands at 7.6% today. This significant increase suggests a changing landscape in societal acceptance and self-recognition of diverse sexual orientations and gender identities.

The rise in LGBT identification, particularly among Gen Z, where a large portion identifies as bisexual, may reflect greater societal acceptance and visibility. Older generations, like Boomers, who identify as LGBT are more likely to describe themselves as lesbian or gay, which may indicate a previous era's more restrictive understanding of sexuality. The broader acceptance of bisexuality today suggests that individuals who might not have previously explored or accepted this aspect of their identity now feel more comfortable doing so.

Moreover, the acceptance of non-binary identities within the transgender community has also grown. Historically, societal acceptance was generally extended only to those who presented themselves fully as either female or male—transgender women or men. There is increasing recognition and support for individuals who identify outside these binary categories, acknowledging those who feel they lie somewhere in the middle, embody elements of both, or do not fit into the binary at all. This shift is critical in understanding the increase in individuals identifying as transgender or non-binary.

Gender Diversity in Children

Gender diversity in children is a normal aspect of developmental progression. From as early as two or three years old, children begin to recognize and interact with the concept of gender, understanding its social elements. In preschool, it's common to see children gravitating toward certain toys or clothing traditionally associated with a particular gender—boys opting for dolls or wearing tutus and girls preferring boys' attire and rejecting the color pink.

It's crucial to recognize that such expressions of gender diversity in young children are not indicative of a pathological condition. Nor do they necessarily predict a future transgender identity or gender incongruence. For example, a boy who enjoys wearing tutus might grow up to identify as a man, possibly as a more feminine man or as a gay man, reflecting variations in sexual orientation rather than gender identity. Similarly, femininity in cisgender gay men or masculinity in straight women are expressions of gender diversity that don't strictly align with transgender or non-binary identities.

Gender expression in children is fluid and cannot reliably predict future gender identity. A child showing gender-diverse traits may grow up to identify within a range of possibilities—from continuing to embrace a gender-diverse identity, to identifying as a feminine man or masculine woman, or not aligning with any of these categories permanently. Essentially, there is no fixed path or clear predictor for how a child's gender identity will evolve.

Understanding this fluidity is vital in supporting gender-diverse children. We recognize gender diversity not as an anomaly but as a part of the broader spectrum of human development that occurs naturally alongside the emergence of gender awareness in children. This perspective is fundamental when discussing what gender diversity means for children and how to support their growth in a nurturing and affirming environment.

Gender Diversity in Adolescence

Gender diversity in adolescence presents unique considerations. In discussions about adolescence, including those within WPATH (World Professional Association for Transgender Health), we typically consider this period as extending from puberty to the age of maturity. However, the exact parameters of adolescence aren't strictly defined, as puberty can start very early in some children, and cognitive development, particularly executive control neural systems, continues into the mid-twenties. This development challenges the notion that turning 18 automatically signifies the transition from adolescence to adulthood, as cognitive development continues well past this age.

In the United States, the age of majority is 18, but it's important to recognize that this age can range from 15 to 21 in other countries. Moreover, turning 18 doesn't necessarily equate with immediate independence or adult responsibilities. Many individuals continue to depend on their parents well into their mid-twenties, which is why considerations relevant to adolescents often apply to transitional-age youth—those from the age of majority up to about 25. These young adults are navigating the complex journey from adolescence to full adulthood, dealing with both social and psychosocial challenges.

Legally, the standards of care for adolescents apply up until the age of 18. After this, adult standards of care take precedence. It's also crucial to acknowledge that some adolescents may experience gender incongruence from childhood, while others only encounter these feelings during puberty—a time of significant physical and gender development that can trigger the onset of gender dysphoria or incongruence.

Regarding terminology, "dysphoria" and "incongruence" are often used interchangeably, though they represent a diagnostic distinction between DSM-5 and ICD-11 frameworks. These terms describe a mismatch between an individual's gender assigned at birth and their experienced gender.

Adolescence is a pivotal time for gender identity development, which often begins in childhood but intensifies during puberty. Influences such as social media and peer interactions play significant roles in shaping gender expectations and identities during this time. As adolescents learn and navigate these influences, their understanding of gender and identity continues to evolve, making adolescence a critical period for support and guidance in gender identity development.

A comprehensive clinical approach is crucial when working with transgender adolescents. This approach is necessary partly because adolescents must be able to understand hypothetical situations to give informed consent for treatments that might have long-term effects. Children often struggle with this concept, but adolescents are generally developing the cognitive awareness needed to think about future consequences and cause-and-effect relationships. However, it's also common for adolescents to display risk-taking behaviors and experience a sense of urgency, perceiving time differently than adults.

Those of you who have worked with teenagers, especially those in distress like depression, might notice that they have difficulty envisioning a life different from their current situation. They often feel an immediate need for change, driven by a heightened sensitivity to rewards, which focuses their attention on short-term outcomes rather than long-term implications. Additionally, adolescents place significant importance on peer relationships, which can be a source of support or a risk factor, depending on the health of those relationships. As they seek more autonomy from their parents, the influence of their peers can become even more pivotal.

The variability in maturity among teenagers is notable. For example, a 17 or 18-year-old might exhibit less self-awareness and insight than a 14-year-old. This individuality means that when making decisions about gender-affirming medical treatments—which can have lifelong consequences—it's essential to consider a range of developmental factors.

This nuanced understanding of adolescent development informs our approach to their care. In my presentations on hormone therapy or surgery for adults, the focus on these developmental considerations is less intense, reflecting adults' greater maturity and decision-making capacity. However, with adolescents, we exercise heightened diligence during the assessment process to ensure that decisions about their care are made with a full understanding of the potentially irreversible effects. This careful approach is vital in supporting adolescents as they navigate these critical decisions.

Minority Stress & Mental Health in Trans and Gender-Diverse Youth

Minority Stress Theory

Let's delve into the topic of minority stress and its impact on the mental health of youth. Minority stress theory, developed by Meyer and seen in Figure 2, is a foundational framework for understanding the mental and physical health disparities observed in LGBT individuals, particularly transgender people.

Figure 2. Minority Stress Theory.

Research strongly supports the minority stress theory, suggesting that LGBT people face higher rates of mental and physical health issues. The question arises: Why does this disparity exist? The theory identifies two primary types of stress factors: distal and proximal.

Distal stress factors represent external stressors that significantly affect the well-being of transgender individuals. These include discrimination, rejection by family, peers, or institutions, victimization through physical or verbal abuse, and non-affirmation, such as being deliberately misgendered or called by incorrect pronouns.

The impact of these distal stress factors is profound, directly correlating with severe outcomes. They contribute to a heightened incidence of mental and physical health problems within the transgender community, particularly among transgender youth. Furthermore, these factors are strongly associated with the tragically high rates of suicide observed among transgender individuals.

The direct link between these external stressors and negative health outcomes underscores the critical need for supportive interventions and policies to mitigate these stressors and provide transgender individuals, especially youth, with safer, more affirming environments.

Proximal stress factors involve the internalization of the external stressors described as distal factors. These internal stressors include internalized homophobia or transphobia, where a transgender individual may feel there is something inherently wrong with them due to their identity, leading to feelings of shame, disgust, or severe self-criticism.

Additionally, negative expectations can heavily impact transgender individuals, especially youth. Many feel their future prospects are bleak—believing they will never succeed in personal relationships, career ambitions, or broader societal acceptance. This often results in low self-esteem and confidence, which may not always be directly linked to their gender identity in their own minds but stems from the ongoing internalization of societal rejection and stigma.

Concealment is another significant proximal stress factor. Many transgender individuals may hide their identity by engaging in activities like secretly trying on clothes that affirm their gender identity or purchasing and hiding such items to avoid detection and potential conflict. This behavior is a direct response to the fear and anxiety produced by societal judgment and lack of acceptance.

These proximal stress factors mediate the relationship between external pressures and the negative outcomes they cause, establishing a complex interaction where external abuses become internal struggles that further exacerbate health and well-being issues. This mediation illustrates how distal factors impact individuals directly and indirectly by fostering harmful internal narratives and behaviors.

Furthermore, the concept of multiple minority stress must be considered. This occurs when individuals identify with more than one marginalized group, compounding their experiences of stress and adversity. For example, a transgender person of color may face intersecting prejudices related to both their gender identity and race, intensifying their experience of minority stress and its associated impacts. Understanding and addressing these layered stresses is crucial for supporting the mental and physical health of transgender individuals, particularly those who are navigating multiple marginalized identities.

ADDRESSING Framework

The ADDRESSING framework, developed by Pamela Hayes (2008), is an essential tool for understanding the complexities of individual identity, particularly concerning marginalization, power, and privilege. This framework breaks down various categories contributing to an individual's identity, each linked to potential marginalization. Here's a brief overview of each component within the ADDRESSING acronym:

• Age: Young people and older adults often possess less societal power than adults aged 18 to 65, who typically have more influence.
• Disability (Developmental): Autism is a common example. Individuals with developmental disabilities may experience increased minority stress. Notably, there is a significant overlap between individuals who are autistic and those who are transgender, with higher incidences of autism among transgender populations and vice versa.
• Disability (Acquired): Conditions like traumatic brain injury or spinal cord injuries that occur later in life. Like developmental disabilities, these also lead to increased minority stress and can profoundly impact an individual’s life and identity.
• Religion: Religions other than Christianity often face more marginalization in predominantly Christian societies.
• Ethnicity: Ethnic minorities, or kids of color, generally experience greater marginalization compared to their white peers.
• Socioeconomic Status (SES): Individuals from lower socioeconomic backgrounds have less privilege than those from higher income brackets.
• Sexual Orientation: Within the transgender community, those who are heterosexual typically experience less discrimination compared to transgender individuals who are gay, lesbian, bisexual, or otherwise non-straight. For example, a transgender girl attracted to men is considered straight and may face fewer challenges than a transgender girl attracted to women or both genders. Transgender individuals who are straight have better mental health care. They have more privileges than transgender individuals who are also lesbian, gay, or bisexual.
• Indigenous Heritage: Individuals with indigenous backgrounds can face unique challenges and discrimination, adding another layer to their identity and experiences of marginalization.
• National Origin: The citizenship status of an individual, particularly when they are transgender, can significantly impact their mental health and well-being. Non-U.S. citizens, especially from countries with limited LGBT rights, face ongoing stress due to potential instability in their residency status. For example, I currently have a patient who is a transgender woman from India, sponsored by her company to work in the tech industry, which is notably volatile at the moment, especially in the Bay Area. She lives with the constant fear of losing her job, and if that were to happen, she believes she would have only about 30 to 60 days to find new employment or face deportation to India, where she would have far fewer protections.
• Gender: It's also crucial to acknowledge how gender affects experiences of privilege and marginalization. Transgender individuals and women typically have less privilege compared to cisgender men, facing numerous systemic barriers that impact their social, professional, and personal lives.

Understanding these dimensions of identity through the ADDRESSING framework helps to highlight the intersecting challenges faced by individuals, emphasizing the need for targeted support and inclusive policies to mitigate these pressures.

Impact of Minority Stress

The impact of minority stress on mental health disparities among transgender and gender-diverse youth is significantly influenced by their experiences of discrimination and rejection. Research confirms that support and acceptance from family, friends, and educational institutions play a critical role in the well-being of these youths. When their social environments embrace them, transgender and gender-diverse youth often show good psychological adjustment and resilience.

Conversely, when they lack support, the consequences can be severe. Distal stressors such as discrimination and rejection can lead to these youths feeling ostracized from their school life, exacerbating feelings of isolation. This external rejection often fosters internalized transphobia and low expectations, which can further deepen their sense of isolation and alienation.

Effective coping strategies involve proactive advocacy for inclusion, particularly within educational settings. Working directly with teachers to promote understanding and acceptance and fostering peer support networks are essential actions. Addressing the mental health needs of transgender youth thus requires a holistic approach that involves their families, peers, and schools. These elements are not just supportive aspects of their lives; they are pivotal determinants of a transgender youth's mental health outcomes.

Have You Heard the News? 

The impact of anti-trans legislation is a significant source of minority stress for transgender youth and young adults, manifesting as a profound distal stress factor. A study conducted between September and November of 2021 explored the implications of exposure to news about newly proposed anti-trans legislation and how perceptions of support for this legislation within one's social network—such as from parents or friends—affect these individuals.

The findings were concerning: news consumption related to this legislation was directly associated with increased rumination and physical health symptoms among trans youth and young adults. Furthermore, if these individuals perceived that their social network supported the legislation, they experienced even greater rumination, depressive symptoms, physical health symptoms, and an intensified fear of disclosing their identity.

The study also included open-ended questions, which revealed that this legislation not only affects access to gender-affirming healthcare but also impedes their ability to seek general healthcare services. Many avoid medical settings altogether due to fear of discrimination or past negative experiences. Additionally, the legislative climate has led to an increase in discrimination during medical treatment and prompted unhealthy coping responses among these individuals. These findings highlight a crucial message for policymakers: the laws they propose and enact have real and damaging effects on the mental and physical well-being of trans youth. 

Gender-Affirming Interventions for Trans and Gender-Diverse Youth

Gender-Affirming Care: Social Transition

Gender-affirming interventions for trans and gender-diverse youth are crucial for their well-being and are often misunderstood. Here’s an overview of what these interventions entail and the standards of care involved.

• Name change;
• Pronoun change;
• Change in sex/gender markers (e.g., birth certificate, identification cards, passport, school and medical documentation, etc.);
• Participation in gender-segregated programs (e.g., sports teams, recreational clubs and camps, schools, etc.);
• Bathroom and locker room use;
• Personal expression (e.g., hairstyle, clothing choice, etc.);
• Communication of affirmed gender to others (e.g., social media, classroom or school announcements, letters to extended families or social contacts, etc.). (Coleman et al., 2022)

Social transition is the primary approach for children who are prepubertal, typically younger than 10 or not yet at Tanner stage 2 of puberty. Medical interventions like hormones, puberty blockers, or surgeries are not considered for children who have not reached these developmental milestones. Social transition involves several reversible changes designed to affirm a child's experienced gender. This includes updating their name across various settings to reflect their gender identity, adopting pronouns that align with the child’s gender identity, and changing gender markers on official documents such as birth certificates, school records, and medical documents to reflect the child's affirmed gender. Children are also allowed to participate in activities and programs, such as sports teams, that align with their gender identity.

For prepubertal children, hormonal differences are not yet a factor, which supports their inclusion based on their affirmed gender rather than their sex assigned at birth. Facilitating access to bathrooms and locker rooms that correspond with the child’s gender identity is another aspect of social transition. Supporting the child in expressing themselves through clothing, hairstyle, and other forms of personal presentation that reflect their identity is also key. Additionally, helping to communicate the child’s gender identity to others, which might include social media announcements or letters to extended family members, is part of this process.

These elements of social transition are entirely non-medical and reversible. They are aimed at supporting the child in a way that affirms their identity, which is critical for their psychological and emotional health. 

Gender-Affirming Care: Prosthetics

In addition to social transition, other non-medical, gender-affirming interventions involve prosthetics or specific training to help individuals express their gender identity. These interventions, which do not involve medication or surgery, play a crucial role in aligning one’s external appearance with one's gender identity.

For masculinizing purposes, binders are often used. These compression garments are designed to flatten the chest, creating a more masculine appearance, and are suitable for individuals who have experienced breast development but are not seeking medical treatment. Packers, another form of prosthetic, are utilized to create the appearance of a bulge in the genital area, simulating the presence of a penis. STP (stand-to-pee) devices enable individuals who do not have a penis to urinate while standing. These devices are shaped to function as prosthetics and urinary aids.

For feminizing effects, gaffs and tucking are common practices. Tucking involves repositioning the penis and testicles to achieve a smoother appearance in tight clothing, while gaffs are specialized undergarments designed to hold these parts securely. Breast forms, worn to simulate the appearance of breasts, enhance the feminine silhouette. Wigs also play an essential role, particularly for individuals who desire longer hair or face challenges with hair loss.

Additionally, aesthetic procedures like laser hair removal aid in achieving a more consistent appearance with one’s gender identity, though their reversibility varies. Voice training is another critical aspect, helping individuals modify their vocal pitch and resonance to better match their gender presentation. While some may seek professional guidance for voice training, others might use self-guided methods.

These gender-affirming interventions, while non-medical, are vital components of the support system for transgender and gender-diverse individuals, offering additional ways to safely and comfortably express their identities.

Gender-Affirming Care

The final piece of gender-affirming care involves medical transition, which consists of three primary categories. The first category includes puberty blockers, also known as GnRH analogs. These blockers prevent the development of endogenous secondary sex characteristics, effectively pausing puberty. This intervention is fully reversible, with no impact on fertility or other puberty-related changes once the treatment is discontinued. Puberty blockers provide adolescents with additional time to explore their gender identity without the distress often associated with puberty. For instance, a 12-year-old at Tanner stage 2 might use puberty blockers to halt puberty, allowing time for further cognitive development and exploration before making decisions about hormones, which are only partially reversible.

Tanner stage 2 marks the onset of visible changes. For those designated female at birth, this stage typically starts between ages 9 and 11 and is characterized by the development of breast buds under the nipples, which may become itchy or tender. The areola, the darker area around the nipple, expands, and the uterus begins to grow. A small amount of pubic hair starts to appear. Tanner stage 2 generally begins around age 11 for those designated male at birth. Changes include enlargement of the testicles and the scrotum, with some pubic hair forming at the base of the penis. It is at this stage that puberty blockers are deemed appropriate, not earlier.

The second category of medical transition involves hormones. For individuals assigned male at birth, the regimen can include estrogen and testosterone blockers, while those assigned female at birth may receive testosterone. The effects of hormone therapy are partially reversible. For example, breast growth induced by estrogen does not recede when hormone treatment is stopped and would require surgical removal if desired. Prolonged hormone use can also impact fertility. Testosterone administration can lead to irreversible changes such as voice deepening and facial and body hair growth. Hair loss, another effect of testosterone, is also irreversible. Fertility effects are generally more reversible for those assigned female at birth taking testosterone compared to those assigned male at birth on estrogen and testosterone blockers.

The third category is surgeries, which are entirely irreversible. While reconstructive surgeries are possible, they do not fully reverse the original alterations. Masculinizing top surgery, or double mastectomy, is the most common procedure performed under age 18, typically starting at age 16. This procedure achieves a flatter chest appearance. Most other surgeries are recommended after age 18.

WPATH Standards of Care 8: Children

Continuing with the Standards of Care 8, we focus now on children, particularly those who are pre-puberty. It is crucial to emphasize that the standards of care do not involve any medical interventions for these children. Instead, the focus is on providing support through knowledge and understanding.

• 7.1 - We recommend health care professionals working with gender-diverse children receive training and have expertise in gender development and gender diversity in children and possess a general knowledge of gender diversity across the life span. 
• 7.2 - We recommend health care professionals working with gender-diverse children receive theoretical and evidenced-based training and develop expertise in general child and family mental health across the developmental spectrum. 
• 7.3 - We recommend health care professionals working with gender-diverse children receive training and develop expertise in autism spectrum disorders and other neurodiversity or collaborate with an expert with relevant expertise when working with autistic/neurodivergent, gender-diverse children
• 7.4 - We recommend health care professionals working with gender-diverse children engage in continuing education related to gender-diverse children and families. 
• 7.5 - We recommend health care professionals conducting an assessment with gender-diverse children access and integrate information from multiple sources as part of the assessment. 
• 7.6 - We recommend health care professionals conducting an assessment with gender-diverse children consider relevant developmental factors, neurocognitive functioning, and language skills. 
• 7.7 - We recommend health care professionals conducting an assessment with gender-diverse children consider factors that may constrain accurate reporting of gender identity/gender expression by the child and/or family/caregiver(s).
• 7.8 - We recommend health care professionals consider consultation, psychotherapy, or both for a gender-diverse child and family/ caregivers when families and health care professionals believe this would benefit the well-being and development of a child and/or family.
• 7.9 - We recommend health care professionals offering consultation, psychotherapy, or both to gender-diverse children and families/caregivers work with other settings and individuals important to the child to promote the child's resilience and emotional well-being.
• 7.10 - We recommend health care professionals offering consultation, psychotherapy, or both to gender-diverse children and families/caregivers provide both parties with age-appropriate psychoeducation about gender development.
• 7.11 - We recommend that health care professionals provide information to gender-diverse children and their families/caregivers as the child approaches puberty about potential gender-affirming medical interventions, the effects of these treatments on future fertility, and options for fertility preservation. 
• 7.12 - We recommend parents/caregivers and health care professionals respond supportively to children who desire to be acknowledged as the gender that matches their internal sense of gender identity. 
• 7.13 - We recommend health care professionals and parents/caregivers support children to continue to explore their gender throughout the pre-pubescent years, regardless of social transition. 
• 7.14 - We recommend the health care professionals discuss the potential benefits and risks of a social transition with families who are considering it. 
• 7.15 - We suggest health care professionals consider working collaboratively with other professionals and organizations to promote the well-being of gender-diverse children and minimize the adversities they may face.

Healthcare professionals working with gender-diverse children must be well-trained in gender diversity across the lifespan. This training should also encompass general child and family mental health and expertise in working with neurodiverse conditions such as autism spectrum disorders and ADHD. For those without direct training in these areas, collaboration with experts who possess this knowledge is essential. This is particularly important given the noted overlap between transgender identities and autism; many autistic children are trans, and vice versa, though the reasons for this correlation are not fully understood and continue to be a subject of research.

The diagnostic criteria for autism, primarily based on studies of cisgender boys, may not accurately reflect the experiences of cisgender girls or transgender children. Recent research indicates that the manifestation of autism characteristics can differ significantly in these groups compared to the established DSM-5 criteria. This highlights the necessity for ongoing education and adaptation of diagnostic approaches to better serve a diverse population.

WPATH also emphasizes the importance of continuous professional development. Healthcare providers are encouraged to pursue continuing education to stay abreast of evolving practices and theories, ensuring they are equipped to provide the most effective support. Conducting comprehensive assessments that integrate information from multiple sources is also recommended. These assessments should aim to develop tailored intervention recommendations that support the child's mental health and well-being without pushing medical transitions.

It is crucial that assessments and interventions neither encourage nor discourage a child’s gender expression. The goal is to support the child in a manner that respects their self-identified gender needs. Assessments should thoroughly consider the child's environment, including family, school, and community contexts, utilizing multiple informants such as teachers, parents, extended family members, and other community figures to comprehensively understand the child’s situation.

Understanding the legal context in which the child lives is also vital. For example, if a child resides in Texas, it is important to know the specific legal implications for transgender youth in that state. Assessments might explore various dimensions such as the child’s gender identity and expression, any dysphoria or incongruence they experience, the strengths and challenges faced by the child and their family, experiences of gender minority stress, levels of support within the school, faith community, and extended family, potential conflicts within the family regarding the child’s gender, and the child’s overall mental health.

In comprehensive assessments for transgender and gender-diverse children, it's vital to gather a detailed medical and developmental history. This includes identifying any potential risks such as past trauma, abuse, suicidality, and co-occurring family stressors like chronic illness, homelessness, or poverty. Understanding the mental health of parents, caregivers, and siblings and the family's overall dynamics is also crucial.

Additionally, assessing the child's neurocognitive functioning and language skills is important. These factors can influence how accurately the child and their family report gender identity and expression. External pressures from family or school environments may compel a child to conform to certain gender expressions, and recognizing these influences is essential for accurate assessment and support.

Continuing education is imperative in this field. Professionals must stay informed about legislative changes, ongoing research, and evolving best practices. The recent introduction of the Standards of Care 8 underscores the importance of keeping knowledge current. In cases where it benefits the child and family, consultation or psychotherapy can be valuable, and it's crucial that this care coordinates with other aspects of the child’s life, such as school and faith communities.

Providing psychoeducation is a crucial element of working with transgender children and their families. Parents and children often require extensive information, especially as children approach puberty and begin considering their options regarding gender-affirming medical treatments. It is vital for healthcare providers to offer comprehensive details about available interventions, such as puberty blockers, ensuring that the family fully understands their effects and implications.

If a child expresses interest in exploring gender-affirming treatments, it is essential to discuss the potential impacts on fertility, as this is a common concern among families. Discussing fertility preservation options can help alleviate some anxieties about the future and aid families in making informed decisions. However, it's important to remember that if a child or their parents are not interested in these treatments, they should not be pressured or obligated to consider them.

Supporting a child's exploration of their gender identity is fundamental, whether or not they choose to socially transition. This support includes affirming the child's gender identity in a manner that respects their individuality and personal journey. It's also worth noting that a social transition can vary across different contexts. For example, a child might transition socially at home but not at school. Whether or not to disclose a social transition is a personal decision and should be guided by the child's comfort and safety, especially in environments where anti-trans legislation may affect their rights.

Additionally, it is crucial to address any concerns the family might have about sexual functioning, which can be a sensitive topic for some. While not all families will want to discuss this aspect, providing clear and age-appropriate information is essential for those who do. Furthermore, sex education should be introduced before puberty. This education should be inclusive, providing all children, including those who are transgender or gender-diverse, with the knowledge they need to understand their bodies and the changes they will undergo. This preparation concerns physical health and fosters a supportive environment that respects and affirms the child's developing identity.

When discussing social transition for transgender children, it is essential that the initiative for such a transition originates from the children themselves, not from assumptions made by their parents. For example, a parent should not deduce a child’s gender identity simply because they dislike traditionally gender-typed colors like pink and suggest the child might be a boy. Instead, the child should express their own desires and interests, and the transition should reflect their wishes.

Families can discuss with the child the advantages and disadvantages of social transitioning. It's important to note that social transition may occur in varying contexts; a child might transition at home but not at school, which is acceptable. Sometimes, a child may socially transition at a very young age, around 3 to 6 years old. In these cases, it's possible that neither their classmates nor their teachers are aware of the transition. This lack of disclosure is generally acceptable and often preferred to protect the child's privacy. This privacy should be respected unless external circumstances, such as anti-trans legislation, require disclosure. However, ideally, no one should be compelled to discuss their transgender identity involuntarily.

Exploring the risks and benefits of social transitioning is crucial. On the positive side, social transitioning can significantly enhance a child’s psychosocial adjustment and overall well-being. Research indicates that the mental health of socially transitioned children often parallels that of their cisgender siblings and peers, suggesting fewer mental health disparities than those observed in gender-diverse children and adolescents who have not transitioned socially. Supportive family environments frequently accompany these transitions and likely contribute to positive mental health outcomes.

However, there are potential downsides. Social transition may expose children to risks such as bullying or ostracism, particularly if they do not conform to established gender roles within their school or community. Additionally, the internal stress from experiencing gender incongruence can be a source of distress for gender-diverse children. 

Importantly, all children, including those who are transgender and gender-diverse, have the right to be supported and respected in their gender identities. They are a particularly vulnerable group, and the social determinants of health significantly impact their well-being. For these marginalized minorities, robust support from families and schools is crucial, playing a critical role in fostering their health and overall development.

WPATH Standards of Care 8: Adolescents

Let's switch our focus to adolescents. When discussing this age group, we refer to the Standards of Care 8 outlined by WPATH. It’s important to note that the numbers I mention correspond to specific standards within these guidelines.

• 6.1 - We recommend health care professionals working with gender-diverse adolescents:
  • 6.1.a - Are licensed by their statutory body and hold a postgraduate degree or its equivalent in a clinical field relevant to this role granted by a nationally accredited statutory institution.
  • 6.1.b - Receive theoretical and evidenced-based training and develop expertise in general child, adolescent, and family mental health across the developmental spectrum.
  • 6.1.c - Receive training and have expertise in gender identity development, gender diversity in children and adolescents, have the ability to assess capacity to assent/consent, and possess general knowledge of gender diversity across the life span.
  • 6.1.d - Receive training and develop expertise in autism spectrum disorders and other neurodevelopmental presentations or collaborate with a developmental disability expert when working with autistic/neurodivergent gender-diverse adolescents
  • 6.1.e - Continue engaging in professional development in all areas relevant to gender-diverse children, adolescents, and families.
• 6.2 - We recommend health care professionals working with gender-diverse adolescents facilitate the exploration and expression of gender openly and respectfully so that no one particular identity is favored.
• 6.3 - We recommend health care professionals working with gender-diverse adolescents undertake a comprehensive biopsychosocial assessment of adolescents who present with gender identity-related concerns and seek medical/surgical transition-related care, and that this be accomplished in a collaborative and supportive manner.
• 6.4 - We recommend health care professionals work with families, schools, and other relevant settings to promote acceptance of gender-diverse expressions of behavior and identities of the adolescent.
• 6.5 - We recommend against offering reparative and conversion therapy aimed at trying to change a person’s gender and lived gender expression to become more congruent with the sex assigned at birth.
• 6.6 - We suggest health care professionals provide transgender and gender-diverse adolescents with health education on chest binding and genital tucking, including a review of the benefits and risks.
• 6.7 - We recommend providers consider prescribing menstrual suppression agents for adolescents experiencing gender incongruence who may not desire testosterone therapy, who desire but have not yet begun testosterone therapy, or in conjunction with testosterone therapy for breakthrough bleeding.
• 6.8 - We recommend health care professionals maintain an ongoing relationship with the gender diverse and transgender adolescent and any relevant caregivers to support the adolescent in their decision-making throughout the duration of puberty suppression treatment, hormonal treatment, and gender-related surgery until the transition is made to adult care.
• 6.9 - We recommend health care professionals involve relevant disciplines, including mental health and medical professionals, to reach a decision about whether puberty suppression, hormone initiation, or gender-related surgery for gender-diverse and transgender adolescents are appropriate and remain indicated throughout the course of treatment until the transition is made to adult care.
• 6.10 - We recommend health care professionals working with transgender and gender-diverse adolescents requesting gender-affirming medical or surgical treatments inform them, prior to initiating treatment, of the reproductive effects, including the potential loss of fertility and available options to preserve fertility within the context of the youth's stage of pubertal development.
• 6.11 - We recommend when gender-affirming medical or surgical treatments are indicated for adolescents, health care professionals working with transgender and gender-diverse adolescents involve parent(s)/guardian(s) in the assessment and treatment process, unless their involvement is determined to be harmful to the adolescent or not feasible.

The first standard involves the requisite training, licensing, and credentials necessary when working with transgender adolescents. Importantly, while one does not need to be a mental health professional to assess a transgender-diverse adolescent, mental health professionals are generally best suited for this role. Typically, it is recommended that a mental health professional conduct assessments, especially those related to blockers, hormones, or surgery. However, a well-trained primary care physician could also competently perform this evaluation.

Additionally, those working with autistic or neurodivergent adolescents should seek ongoing training and professional development to ensure they are providing the most informed and effective care. It's crucial to facilitate the exploration and expression of gender in an open and respectful manner, ensuring that no specific identity is favored. This means avoiding any bias that might influence an adolescent either to embrace or reject a trans identity or to adhere strictly to the gender assigned at birth. The goal is to maintain a neutral, supportive space that allows youth to explore their identity at their own pace.

Conducting a comprehensive biopsychosocial assessment of adolescents is essential in a collaborative and supportive manner. It's important to recognize that not all children who are gender-diverse will continue to identify this way into adolescence. Similarly, adolescents may vary significantly in how quickly they consolidate their gender identity. This process occurs rapidly for some, while it evolves more slowly for others. This variability underscores the need to meet each youth where they are and proceed at a pace that respects their individual process.

Robust evidence supports the benefits of gender-affirming medical treatments in adolescents, but it's crucial to note that this evidence is based on clinical settings that incorporated detailed, comprehensive diagnostic assessments over time. There is no supportive evidence for making medical or surgical decisions without a thorough and prolonged assessment process. Therefore, the recommendation is clear: comprehensive diagnostic biopsychosocial assessments are necessary and represent the evidence-based approach for managing gender-diverse youth.

When working with families and schools, similar to interactions with children, it's crucial to avoid any approaches akin to reparative or conversion therapy. Such practices, aimed at changing a child's experience of their gender or eliminating gender incongruence, are not only ineffective but also harmful and unethical. Extensive research indicates that these methods can have detrimental effects on adolescents' well-being.

Health education on tucking and binding is also essential. If patients are engaging in these practices or are interested in doing so, it is important to provide proper guidance. Many teens might be tucking and binding unsafely, using materials like ace bandages or excessively tight tape, which can disrupt circulation and lead to issues such as back and chest pain, shortness of breath, and overheating. For example, one patient reported wearing two to three binders simultaneously, keeping them on while sleeping and during exercise, which is highly inadvisable. Binders are not meant for prolonged wear, especially not during sleep or physical activity, and should not be substituted with ace bandages. There are binders specifically designed for safe use, and these should be recommended instead. Notably, 87% of transgender masculine individuals, those designated female at birth who are transitioning to a more masculine identity, have a history of binding.

Discussing tucking, which involves retracting the testes and penis for a smoother appearance at the groin, is also crucial. This practice can affect sperm production and fertility, necessitating thorough educational support on these topics. Menstrual suppression is another consideration; it can be managed with various agents, regardless of whether the patient is using testosterone or puberty blockers. Some individuals may opt only for menstrual suppression without pursuing hormone therapy. Just as some cisgender women choose not to menstruate for personal comfort, similar options should be accessible for transgender individuals. Options include estrogen and progestin medications, oral progestins, and IUDs.

Puberty blockers, or GnRH (Gonadotropin-releasing hormones) analogs, can also suppress menstruation. However, testosterone, while it can suppress menstruation, may not immediately stop uterine bleeding, and breakthrough bleeding can occur. Importantly, testosterone is not a form of birth control and is teratogenic, meaning it can cause harmful effects on a fetus if pregnancy occurs. Therefore, it is vital to provide sex education and discuss birth control options with sexually active patients who could become pregnant, even if they are not menstruating. Ovulation and the potential for pregnancy can still occur in individuals using testosterone or puberty blockers who do not menstruate.

Providing ongoing support throughout the duration of puberty suppression, hormone treatment, or surgical interventions is crucial until the transition to adult care is complete. This process should not be limited to a single evaluation, after which the adolescent is sent on their way with prescriptions for hormones or puberty blockers. Decision-making is an ongoing process that requires constant support, especially as adolescents experience changes that might affect them differently than anticipated.

All of the research and evidence supporting these interventions were conducted in settings that fostered ongoing clinical relationships between the adolescents, their families, and their providers. This continuous support within multidisciplinary settings, where medical and mental health professionals collaborate closely, is essential for effective treatment. It’s important to understand that the evidence base comes from these types of collaborative environments.

Both medical and mental health professionals should be involved in both the initial evaluation and the ongoing care concerning blockers, hormones, and surgery. It’s not sufficient to have only mental health support; medical professionals must also be involved. While only one letter from a professional is required to proceed with treatment, this letter should reflect the entire team's comprehensive assessment and consensus, encompassing medical and mental health perspectives.

The multidisciplinary team might include professionals from various fields, such as adolescent medicine or primary care, which is often needed to confirm the stage of puberty. Endocrinologists may be required to prescribe hormones or puberty blockers, while psychologists, psychiatrists, and social workers address mental health aspects. Speech-language pathologists might be involved in voice training, along with support staff and the surgical team.

Discussing fertility is crucial when considering gender-affirming treatments for adolescents. It is essential to address the potential for fertility loss associated with various treatments and explore options for fertility preservation.

Puberty blockers are fully reversible, meaning they do not typically impact long-term fertility. However, transitioning directly from puberty blockers to hormones could potentially result in fertility loss. Furthermore, genital surgeries, although less common among adolescents, can have an irreversible impact on fertility. Therefore, discussing fertility preservation options, such as egg retrieval or sperm preservation, is important. It is vital that both parents and the adolescent understand the pros and cons of these options thoroughly.

Differences in perspective between parents and adolescents regarding reproductive capacity can lead to disagreements. Parents might place a high value on the potential for grandchildren, whereas the adolescent may express a clear disinterest in having children. Such disparities underscore the importance of facilitated discussions that help both parties understand each other’s viewpoints and the implications of treatment decisions.

It is also crucial to consider the adolescent’s decision-making competency regarding their future reproductive choices. While many adolescents feel certain about not wanting children, their desires and life circumstances could change as they mature. Guidance from professionals experienced in adolescent development and family dynamics is essential in these discussions. These professionals should help set realistic expectations for fertility preservation outcomes and ensure that these discussions are informed and based on the adolescent’s and family’s needs and values. These conversations need to occur both before initiating any medical intervention and throughout transition.

Fertility counseling is often recommended, even if preservation is not pursued. However, it is important not to coerce adolescents into fertility preservation if it is not aligned with their or their parents’ wishes. Procedures like egg retrieval can be distressing and physically uncomfortable, particularly for transmasculine individuals, due to the highly gendered nature of most reproductive health environments.

I'm currently working with an adult patient who was going through the egg retrieval process prior to continuing on testosterone. They experienced significant anxiety, partly because they had previously undergone the procedure. The environment, heavily feminized with images of women, did not align with their transmasculine identity, adding to their discomfort. They also found the process physically uncomfortable and painful.

These considerations must be navigated sensitively, ensuring that discussions about fertility preservation are inclusive and respectful of the adolescent’s gender identity and personal preferences. The decision to undergo fertility preservation is complex and must balance medical possibilities with the psychological comfort and personal desires of the adolescent, making professional guidance and open communication essential throughout the process.

It's crucial not to make assumptions about an adolescent's goals, especially given the limited research in this area. There is existing research involving childhood cancer survivors, which suggests that some participants experienced regret and distress over missed opportunities for fertility preservation. However, the experiences of transgender individuals may differ significantly.

Involving parents or guardians in both assessment and treatment is generally standard practice, with the assessment often occurring over multiple sessions—individually with the child, with the parents, and then together. This process can be extensive. Exceptions may occur, such as in cases where the adolescent is in foster care, under Child Protective Services, or where parental involvement might be harmful due to issues like abuse. However, in the majority of cases, parental or guardian involvement is crucial. Depending on the institution’s policy, consent from one or both parents might be necessary.

Parents and caregivers can provide valuable insights into the adolescent's gender development, medical and mental health history, and overall level of functioning. Discrepancies in reports between the adolescent and their parents about mental health can also provide critical information for understanding the youth's needs.

Working closely with parents is vital. It is essential to educate them about the treatment process, follow-up care, and potential complications. It’s important to take parents' concerns seriously and address their questions thoroughly, which can help in assessing the influence of peers or social media on the adolescent's understanding of gender.

There may be instances where parents do not consent to treatment. While some may still be generally supportive of their child’s gender identity, others may hold unsupportive or even antagonistic views. These perspectives, while challenging, are important to engage with as part of the therapeutic process. Many parents, with appropriate support and psychoeducation, may become more accepting and supportive of their trans and gender-diverse children over time.

Thus, continuing to work with families remains critical regardless of their initial stance on medical care. Even if a parent does not consent to specific treatments, supporting them can still positively impact the family dynamics and the well-being of the adolescent.

The following recommendations are made regarding the requirements for gender-affirming medical and surgical treatment (All of them must be met):

• 6.12 - We recommend health care professionals assessing transgender and gender-diverse adolescents only recommend gender-affirming medical or surgical treatments requested by the patient when:
  • 6.12.a - The adolescent meets the diagnostic criteria of gender incongruence as per the ICD-11 in situations where a diagnosis is necessary to access health care. In countries that have not implemented the latest ICD, other taxonomies may be used, although efforts should be undertaken to utilize the latest ICD as soon as practicable.
  • 6.12.b - The experience of gender diversity/incongruence is marked and sustained over time.
  • 6.12.c - The adolescent demonstrates the emotional and cognitive maturity required to provide informed consent/assent for the treatment.
  • 6.12.d - The adolescent’s mental health concerns (if any) that may interfere with diagnostic clarity, capacity to consent, and gender-affirming medical treatments have been addressed.
  • 6.12.e - The adolescent has been informed of the reproductive effects, including the potential loss of fertility and the available options to preserve fertility, and these have been discussed in the context of the adolescent’s stage of pubertal development.
  • 6.12.f - The adolescent has reached Tanner stage 2 of puberty for pubertal suppression to be initiated.
  • 6.12.g - The adolescent had at least 12 months of gender-affirming hormone therapy or longer, if required, to achieve the desired surgical result for gender-affirming procedures, including breast augmentation, orchiectomy, vaginoplasty, hysterectomy, phalloplasty, metoidioplasty, and facial surgery as part of gender-affirming treatment unless hormone therapy is either not desired or is medically contraindicated.

When discussing gender-affirming medical and surgical treatments, it's imperative that the adolescent meets the diagnostic criteria for gender incongruence as outlined in the ICD-11. If the ICD-11 is not yet implemented within a specific healthcare system, an alternative classification, such as the DSM-5, may be used. However, the ICD-11 is generally preferred because it categorizes gender incongruence under conditions related to sexual health rather than mental and behavioral disorders. This shift is significant as it reflects a more current understanding that gender diversity is not a mental health condition, similar to historical changes in the classification of homosexuality.

The ICD-11 allows for diagnoses such as gender incongruence of adolescence or adulthood (HA60) for adolescents, gender incongruence of childhood (HA61) for children, or unspecified gender incongruence (HA6Z). This classification is less pathologizing and helps reduce stigma compared to the DSM-5’s diagnosis of gender dysphoria.

It's essential to recognize that adolescents may experience shifts in their gender-related experiences and needs. Therefore, they should ideally demonstrate several years of persistent gender diversity and incongruence before initiating less reversible treatments such as hormones or surgery. Puberty suppression is particularly beneficial as it can provide adolescents experiencing distress from the changes associated with puberty the time to decide if they want to undergo the typical changes of their biological puberty or pursue hormone therapy.

However, prolonged periods without hormones can impact bone health and density, making the extended use of puberty suppression treatments a complex decision. While several years of observation and assessment are ideal, practical considerations, including potential impacts on physical health, must also be taken into account. Social transition can provide significant relief and additional time for adolescents to explore their gender identity before making any medical decisions.

While we have already discussed reproduction and fertility, it is vital to reiterate the importance of these topics in the context of gender-affirming care.

A critical aspect of treating adolescents involves ensuring they have the emotional and cognitive maturity to consent to or assent to treatment. This typically requires both parental consent and the adolescent's assent. The adolescent must fully understand the treatment, including the ability to evaluate the risks and benefits. They must appreciate the nature of their decision, especially considering the long-term consequences of irreversible treatments such as hormone therapy or surgery.

To make an informed decision, adolescents need to clearly communicate their choices and understand the timelines for expected changes from treatments like hormones. They should be aware of what is reversible, partially reversible, and irreversible, weighing all the pros and cons to determine if the treatment aligns with their needs.

It's crucial to assess whether the adolescent can thoughtfully consider the future implications of partially or fully irreversible interventions. This includes evaluating if they have the self-reflective capacity to understand how their gender-related needs and priorities might evolve over time. Adolescents should consider their responses if their perspectives on gender identity change in the future.

Additionally, it's essential to determine if the adolescent can manage the day-to-day and long-term aspects of a medical treatment. This includes adhering to medication schedules, attending necessary medical follow-ups, and handling any associated responsibilities.

When considering the capacity to consent, it's essential to evaluate all aspects thoroughly, particularly mental health concerns, which are prevalent among transgender youth. This demographic may face a range of mental health issues, including depression, self-harm, suicidality, and eating disorders. When such concerns are present, the priority must be safety and stabilization. For instance, an adolescent grappling with suicidality or an active eating disorder may not be in a position to make informed decisions about gender-affirming medical or surgical treatments. Furthermore, these conditions could potentially destabilize them further, prompting careful consideration of whether they are ready for such treatments.

Mental health concerns can also complicate the assessment process. It may be challenging to distinguish between gender incongruence and other mental health issues, such as compulsions, special interests associated with autism, or symptoms stemming from trauma or psychosis. Such complexities necessitate a nuanced approach to evaluating the adolescent's true needs and readiness for transition-related care.

Moreover, if an adolescent is experiencing a depressive episode, it could impair their ability to engage in thoughtful decision-making. For autistic adolescents, persistent communication differences and a preference for concrete or rigid thinking can further complicate discussions around treatment options and future planning.

Treatment adherence is another critical consideration. An adolescent dealing with severe depression might struggle to consistently take prescribed medications or follow through with post-surgical care. While mental health issues do not need to be fully resolved before proceeding with gender-affirming treatment, they must be sufficiently managed to ensure the adolescent can safely participate in and benefit from treatment.

Regarding treatment timing, it's crucial that adolescents reach Tanner stage 2 before initiating puberty blockers. For hormones and surgery, the recommendation generally includes at least 12 months on hormones before considering surgical options. This duration allows for anatomical changes necessary for certain procedures, such as breast augmentation, and ensures that the adolescent has adequate time to psychologically adjust to the physical changes hormones induce.

Gender-Affirming Care: Outcomes

Let's discuss the outcomes associated with gender-affirming interventions. There is substantial evidence indicating that these interventions improve mental health outcomes. These interventions, which include puberty blockers, hormone therapy, and surgery, have been shown to lead to a resolution in gender dysphoria. This resolution is often associated with enhanced psychological functioning and increased satisfaction with body image.

It's important to note that trans adolescents generally exhibit poorer mental health compared to their cisgender peers. However, studies have shown that after undergoing puberty suppression, their mental health tends to improve significantly. Additionally, trans males who have undergone hormone therapy report lower levels of depression and anxiety compared to those who have not yet started hormone treatments. These findings underscore the potential benefits of gender-affirming interventions in improving mental health.

It's crucial to recognize that while these interventions can markedly enhance mental health, their impact varies. Not all adolescents will experience the same benefits, particularly if they have preexisting mental health issues. Gender-affirming treatments specifically address gender dysphoria; they do not directly treat other mental health conditions. Therefore, it is possible for an adolescent to continue experiencing mental health challenges even after undergoing hormone treatments, surgery, or puberty blockers. This highlights the importance of comprehensive mental health care that addresses all aspects of an adolescent’s well-being, not just those related to gender dysphoria.

What About Regret & Detransition?

Research concerning regret and detransition is a topic that garners significant attention, often highlighted in various articles due to public concern. However, studies indicate that the rates of adolescents choosing to cease puberty blockers are relatively low. For example, two Dutch studies from 2018 and 2019 found that only about 2% to 3.5% of adolescents chose to stop puberty suppression. It's crucial to note that puberty suppression is entirely reversible, so stopping these treatments does not result in long-term or sustained effects.

Regarding detransition, research shows that while some adolescents do detransition, they do not necessarily regret initiating treatment. For instance, an individual might have achieved the desired irreversible effects from hormone therapy, such as a lower voice, and choose to discontinue treatment while still feeling positive about the decision to start it.

A significant study conducted between 2014 and 2020 by a gender diversity service in Western Australia that provides gender-affirming care to children and adolescents up to 18 years tracked 552 closed referrals and provided insightful data. Out of the 548 patients included in the study, only a very small percentage, 5.3%, re-identified with their birth sex after being referred. Remarkably, only two patients, approximately 1% of those who received some form of treatment such as puberty suppression or hormones, later re-identified with their birth sex. The findings suggest that some individuals might re-identify during the assessment process and choose not to proceed with treatment.

It is essential to distinguish between detransition and regret. Detransition refers to the cessation of the medical transitioning process, which does not necessarily imply regret about the decision to start. Furthermore, the rates of re-identifying with the birth sex are exceedingly low, and stopping hormone therapy does not always mean re-identifying with one's birth sex. Individuals might continue to identify with the same or a different transgender identity but decide against continuing medical transition.

This complexity underscores the need for nuanced understanding and support in the realm of gender-affirming care, recognizing that the paths of gender identity and transition are highly individual and not uniformly linear.

Clinical Approaches

Let's briefly review some clinical approaches. Since we've covered these extensively, I'll quickly summarize the key points.

Supporting TGD Youth

• The role of advocacy
  • Join community organizations
  • Join with parents and families
• Provide psychoeducation and training
• Make your voice heard in schools, with medical providers, in politics/courts, and in the media
• Support youth in their families, schools, and communities
• Understand the role of multiple minority stress
• Address barriers to accessing care

Advocacy plays a crucial role in supporting transgender and gender-diverse youth. It is vital to engage with community organizations, collaborate with parents and families, and make one's voice heard in various settings, including schools, medical environments, political arenas, and the media.

Family Interventions

• Providing psychoeducation
• Allowing space for families to express reactions to their child's gender
• Emphasizing the protective power of family acceptance
• Utilizing multiple modalities of support, 
• Giving families opportunities for allyship and advocacy
• Connecting families to TGE community resources
• Centering intersectional approaches and concerns 
• Types of support:
  • Emotional
  • Instrumental 
  • Appraisal
  • Informational
• Parental support is essential!

In working with families, it is important to provide education and space for them to express their reactions to their child's gender identity, even if those reactions are not always positive. Emphasizing the protective power of family acceptance is crucial. Employ multiple modalities of support and provide opportunities for allyship and advocacy. For example, connecting families with advocacy organizations and community resources can help them support their children more effectively. It is also important to consider intersectional approaches, acknowledging that these families may face additional challenges related to other marginalized identities.

Studies have shown that family support can take various forms, including emotional support, such as expressions of love, empathy for mental health issues, and communication about emotions. Instrumental support might include financial assistance, help with healthcare, and support during social and legal transitions. Appraisal involves giving feedback and affirming the child’s gender, helping choose a name, or helping choose pronouns. Informational support includes providing advice and sexual health information. These elements are crucial in helping transgender children feel supported by their families.

Guidelines for Schools

• Create a welcoming environment
• Create antibullying measures – and actually enforce them!
• Provide opportunities to explore medical transition options if indicated 
• Use the youth’s name and pronouns correctly
• Support the youth in connecting with LGBT groups, trusted staff, and peers

It is essential to help schools create a welcoming environment in the educational setting. This involves implementing and enforcing anti-bullying measures, using the youth’s chosen name and pronouns correctly, and providing opportunities for medical transition if indicated. Schools should also facilitate connections with LGBT groups, trusted staff, and LGBT peers. In one school, for example, affirming teachers displayed symbols on their doors to indicate their support, allowing LGBT students to identify allies.

Unfortunately, the risks of inadequate support are starkly highlighted by incidents like the case of Nex Benedict, a non-binary student in Oklahoma. Nex was reportedly bullied and attacked and tragically found dead the following day. This case underscores the severe impact that bullying and lack of support can have on the physical and mental health of transgender youth, emphasizing the importance of robust advocacy and protective measures in all environments that influence the lives of these young individuals.

Ethical Considerations

Ethical considerations are critical, especially when working with transgender youth. As we conclude today's discussion, it's important to emphasize the role of ethical guidelines in guiding professional conduct.

Ethics Codes

Always refer to the ethics codes specific to your profession. These codes provide a framework for addressing the complex situations you may encounter and ensure that you uphold the highest standards of practice. Additionally, be well-informed about the legal and ethical environment in your state. Local laws and regulations can significantly impact how services are provided to transgender youth, and staying informed ensures that your practice meets professional standards and regional legal requirements. Below are links to Ethics Codes for some of the major behavioral health professions. Please ensure you always refer to your own ethical code.

• AAMFT: https://www.aamft.org/Legal_Ethics/Code_of_Ethics.aspx 
• ACA: https://www.counseling.org/resources/ethics
• APA: https://www.apa.org/ethics/code 
• NBCC: https://nbcc.org/assets/ethics/nbcccodeofethics.pdf
• NAADAC: https://www.naadac.org/code-of-ethics
• NASW: https://www.socialworkers.org/About/Ethics/Code-of-Ethics/Code-of-Ethics-English

The Ethics of Gender-Affirming Care

The ethics of gender-affirming care, particularly for transgender youth, involves navigating complex issues that require a nuanced understanding of medical ethics and human rights perspectives. The World Professional Association for Transgender Health (WPATH) and its Standards of Care emphasize the ethical principles of self-determination and the right to access healthcare.

When deemed capable, adolescents should have the autonomy to make decisions about their healthcare. This often involves dual consent—both from the adolescent and their parents. However, the ethical principle of self-determination supports an adolescent's right to choose their own treatment, assuming they have the capacity to consent. This principle is particularly poignant in cases where gender-affirming care is deemed medically necessary, as it is the only treatment known to effectively address gender incongruence and has been shown to lead to significantly positive outcomes.

However, it is crucial to ensure that adolescents receive appropriate education about their treatment options and a thorough and thoughtful assessment process. This ensures they truly understand and can consent to their treatment, safeguarding against potential harm that could arise from treatments they are not fully prepared to undertake.

It is also important to recognize that choosing not to intervene—allowing puberty to progress without interruption—is not a neutral act. For many transgender adolescents, this could lead to intense distress and negative psychological outcomes. Inaction, under the guise of avoiding harm, can itself be harmful.

For example, I am currently working with a 20-year-old who began hormone therapy at around 17 or 18, with parental consent. However, prior to this, there was a period of confusion and non-consent from the parents. During this time, she obtained hormones via the internet, stating that it was life-saving and that her friend, by facilitating access to hormones, literally saved her life. While it's not ideal to encourage unsupervised medical interventions, this situation underscores the lengths to which individuals may go to alleviate their distress.

Moreover, consider the patient who wore three binders to flatten their chest despite the physical pain it caused. This example highlights the severe distress associated with experiencing gender incongruence and the potential risks individuals might take to find relief.

Ethics and the Law

When ethics and law are in conflict, particularly in the realm of gender-affirming care for transgender youth, professionals face significant challenges. Instances where laws may label supportive parents as potential child abusers simply for consenting to gender-affirming care for their children highlight the stark contrasts between ethical medical practices and legal mandates. This was a proposed law in Texas, and a psychologist took that law to court. These situations are distressing, not only to the families affected but also to the professionals involved.

In states where gender-affirming care is restricted or banned, families sometimes resort to extreme measures, such as traveling to neighboring states or even countries where such care is accessible. For example, families in Texas might travel to New Mexico to receive the necessary treatments that are prohibited in their home state. This places a financial and emotional burden on the families and highlights the disparities in healthcare access based on geographical location.

For mental health professionals and psychologists, these conflicts between ethics and law underscore the importance of being actively involved in policymaking. Advocating for laws that reflect current scientific understanding and best practices in healthcare is crucial. Many policymakers may lack awareness of the latest research or the scientific consensus on issues related to gender identity, which can lead to legislation that is not only scientifically unsound but also harmful.

Professionals can leverage their expertise to educate policymakers, participate in legislative processes, and challenge unjust laws in court. The case of the psychologist who took such a law to court is a prime example of how professionals can actively defend ethical practices and support the rights of transgender individuals.

Conversion Therapy

Conversion therapy, often referred to as reparative therapy, attempts to change an individual's sexual orientation or gender identity. It is important to acknowledge that this practice is ineffective and unethical. Research and clinical consensus have demonstrated that gender incongruence cannot be "treated" or altered through such therapeutic approaches; they simply do not work.

Gender-affirming treatments are the only interventions that have been shown to alleviate the distress associated with gender dysphoria. These treatments support the individual’s gender identity rather than attempting to change it, which is crucial for improving mental health outcomes.

Moreover, it's worth noting that conversion therapy is illegal in several states, reflecting its disapproval within the professional community and its recognition as a harmful practice. Engaging in or endorsing conversion therapy goes against the ethical guidelines of most professional bodies in the mental health field. As such, it is vital for professionals to avoid any involvement in practices that attempt to change a person's sexual orientation or gender identity.

Confidentiality

Finally, confidentiality is a critical ethical consideration when working with transgender youth. It is imperative not to disclose a child's gender identity to their parents or family without the child's explicit permission. Often, a child may reveal their gender identity to a healthcare provider while still not being ready to come out to their family.

To manage expectations and protect confidentiality, it is advisable to include specific provisions in the consent forms that are discussed and agreed upon with the parents at the onset of treatment. These provisions should clearly state that while issues of significant risk will prompt a breach of confidentiality — for example, if the child is in danger — the details of the child's gender identity will remain confidential if sharing those details poses no immediate risk.

Furthermore, it is important to discuss with the child the potential mental health impacts of coming out to their family. This conversation can help prepare the child for various outcomes and ensure they are making informed decisions about their disclosure.

Additionally, be cautious about documentation. In large healthcare systems, where multiple providers may access a patient's records or where parents can view their child's medical information, it is crucial to document sensitively. If certain information, such as the child's discussed gender identity, needs to be kept confidential, ensure it is documented in a way that respects the child's privacy.

Overall, establishing clear guidelines about confidentiality from the start with both the child and their parents can prevent misunderstandings and protect the child's privacy while under your care.

Resources

• APA Guidelines for Treatment of Transgender & Gender Diverse Practice 
• WPATH Standards of Care, Version 8
• UCSF Guidelines for the Primary and Gender-Affirming Care of Transgender and Gender Nonbinary People

References

ACLU. (2024). The ACLU is Tracking 484 Anti-LGBTQ Bills in the U.S. Retrieved from https://www.aclu.org/legislative-attacks-on-lgbtq-rights-2024

Andrzejewski, J., Pampati, S., Steiner, R. J., Boyce, L., & Johns, M. M. (2021). Perspectives of transgender youth on parental support: Qualitative findings from the resilience and transgender youth study. Health Education & Behavior, 48(1),74-81.

Call, D. C., Challa, M., & Telingator, C. J. (2021). Providing affirmative care to transgender and gender diverse youth: disparities, interventions, and outcomes. Current Psychiatry Reports, 23, 1-10.

Cavve, B. S., Bickendorf, X., Ball, J., Saunders, L. A., Thomas, C. S., Strauss, P., & Moore, J. K. (2022). Reidentification with birth-registered sex in a Western Australian pediatric gender clinic cohort. JAMA pediatrics, 178(5), 446-453.

Coleman, E., et al. (2022). Standards of care for the health of transgender and gender diverse people, Version 8. International journal of transgender health, 23(Suppl 1), S1–S259. 

Dhanani, L. Y., & Totton, R. R. (2023). Have you heard the news? The effects of exposure to news about recent transgender legislation on transgender youth and young adults. Sexuality Research and Social Policy, 20(4), 1345-1359.

Hays, P. A. (2008). Entering another's world: Understanding clients' identities and contexts. In P. A. Hays, Addressing cultural complexities in practice: Assessment, diagnosis, and therapy (2nd ed., pp. 65–83). American Psychological Association.

Johns, M. M., Zamantakis, A., Andrzejewski, J., Boyce, L., Rasberry, C. N., & Jayne, P. E. (2021). Minority stress, coping, andtransgender youth in schools—Results from the Resilience and Transgender Youth Study. Journal of School Health,91(11), 883-893.

Malpas, J., Pellicane, M. J., & Glaeser, E. (2022). Family-based interventions with transgender and gender expansive youth:Systematic review and best practice recommendations. Transgender Health, 7(1), 7-29.

Reed, E. (2024). Anti-Trans Legislative Risk Assessment Map – February Update. Retrieved from https://www.erininthemorning.com/p/anti-trans-legislative-risk-assessment-96f

Testa, R. J., Habarth, J., Peta, J., Balsam, K., & Bockting, W. (2015). Development of the gender minority stress and resilience measure. Psychology of Sexual Orientation and Gender Diversity, 2(1), 65.

Trans Legislation. (2024). What is Happening With Anti-Trans Bills in 2024? Retrieved from https://translegislation.com/

Additional Current References

Please Note: The following resources have been included for members to view additional resources associated with this topic area. These resources were not used by the presenter when creating this course. 

Georges, E., Brown, E. C. B., & Cohen, R. S. (2024). Prohibition of gender-affirming care as a form of child maltreatment: Reframing the discussion. Pediatrics, 153(1), 1–5.         https://doi.org/10.1542/peds.2023-064292

Handler, T., Merchant, M., Guzik, C., Chen, S., Kralik, N., Ojo, A., & Zaritsky, E. (2024). Diagnosis and time to treatment for pediatric patients with gender dysphoria. Journal of LGBT Youth, 21(1), 20–28. https://doi.org/10.1080/19361653.2022.2139788

Pomarico-Denino, V. (2024). Gender-affirming care for the adolescent patient. Nurse Practitioner, 49(3), 11–18.  https://doi.org/10.1097/01.NPR.0000000000000147

Rangi, S. K., Rehmer, J., & Ferrando, C. A. (2024). Prevalence of Polycystic Ovarian Syndrome in young and adolescent transmasculine patients presenting for gender-affirming care. Journal of Pediatric & Adolescent Gynecology, 37(1), 51–55. https://doi.org/10.1016/j.jpag.2023.09.003

Restar, A. J., Layland, E. K., Davis, B., Thompson, H., & Streed, C. (2024). The public health crisis state of transgender health care and policy. American Journal of Public Health, 114(2), 161–163. https://doi.org/10.2105/AJPH.2023.307523

Editor's Note: This text-based course is an edited transcript of the webinar, Racism and Mental Health, presented by Sophie Nathenson, PhD.

Learning Outcomes

After this course, participants will be able to:

• Identify two mechanisms by which mental health disparities exist by race.
• Describe three examples of institutional racism that influence mental health.
• Explain three clinical or policy-level interventions that address the impact of race and racism on mental health.

Risks and Limitations

This course does not contain a comprehensive summary of research on racism and mental health. It does not contain research specific to every minority group. All the data, including population and methods, is subject to change over time. Research in this presentation may refer to general patterns, but it does not represent any specific organization or set of individuals. 

Roadmap

Here's the roadmap for today's discussion. First, I'll introduce the sociological perspective and its connection with the mental and behavioral health professions. Following that, I'll delve into the multifaceted definition of racism, examining its manifestations at three distinct levels: interpersonal, institutional, and cultural. Subsequently, I'll describe pivotal research findings on the connection between racism and mental health before concluding with a presentation of recommendations drawn from the psychology field aimed at combating racism.

Relevance for Mental Health Professionals

The relevance of this topic for mental health professionals traces back over half a century. While discussions surrounding the impact of racism and discrimination on mental health were undoubtedly occurring prior, it was in the 1970s that a notable surge of publications emerged from the psychology and psychiatry fields. These publications not only delineated the concept of institutional racism but also explained its profound effects on clients. Moreover, they offered actionable strategies and convened task forces dedicated to addressing these issues. A poignant excerpt from one such publication underscores the imperative for white psychiatrists to heighten their awareness of how their everyday practices unwittingly perpetuate institutional white racism within the realm of psychology. “We are asking white psychiatrists to become increasingly aware of how their everyday practices continue to perpetuate institutional white racism in psychiatry…a significant reduction in economic barriers to psychiatric care…relinquishing negative stereotypes” (Sabshin et al.1970). This served as a call to action to interrogate the often unseen external forces that shape clinical interactions and to integrate this awareness into professional practice.

Identifying societal-level factors, such as economic barriers, was of particular significance, which necessitated attention and remediation. One recent publication underscores the assertion that among “all sectors of healthcare, mental health is best equipped to stand against racism” (Mensah, Ogbu-Nwobodo, & Shim, 2021). This assertion transcends the traditional purview of client care, advocating for active engagement beyond the confines of clinical settings. This paradigm shift underscores the recognition that combatting racism requires understanding broader societal issues and a willingness to advocate for systemic change—an aspect I will delve into further.

The Sociological Perspective

I always begin with an exploration of the sociological perspective, as my background lies in medical sociology rather than mental and behavioral healthcare. In this field, our focus is on investigating the underlying social conditions and factors that contribute to health inequalities within society.

While psychology delves into the intricacies of individual differences—examining personal histories, behaviors, emotions, and biological makeup—sociology takes a broader lens, identifying disparities between groups. These groupings may be delineated by various criteria such as age, gender, race, employment status, marital status, or geographical location. It's crucial to note that within these social groupings, individuals are not homogenous; rather, we seek to understand the distinctions between them.

Within the realm of medical sociology, our gaze is fixed on health outcomes, seeking to decipher the societal undercurrents that might give rise to disparities. When we observe statistically significant differences in outcomes between groups, even after accounting for various individual factors, it signals a need to examine the social environment—a factor that may be influencing these divergences.

Racism, within this paradigm, is recognized as a potent social determinant of health, capable of exerting profound impacts on both physical and mental well-being. It's crucial to conceptualize race as a social construct rather than a biologically or genetically determined trait. In this context, being a member of a minority race does not necessarily denote numerical minority status but rather denotes a lack of dominance and may signify disparities in opportunities and power within society.

Within the sociological framework we are adopting today, we are attentive to the influence of social context alongside genetic, physiological, and psychological factors in shaping behavioral patterns and mental health disorders. It's essential to recognize that health outcomes and behaviors are multifaceted and influenced by a myriad of factors. While we focus on societal patterns and their correlation with experiences of racism and discrimination, we acknowledge the intricate interplay between psychology, physiology, genetics, and social dynamics—all of which contribute to the health outcomes. Today, we are zooming in on the societal factors, recognizing that they are but one piece of a complex puzzle.

The Power of Authority and Social Environment

There are a couple of studies that consistently come to mind when contemplating the profound influence of the social environment, particularly on a psychological level.

Stanley Milgram study 

One of the most widely cited studies that underscores the potent influence of the social environment is the Stanley Milgram study, conducted in 1961. In this seminal experiment, participants were assigned roles: an experimenter (the authority figure, V), a teacher (L), and a learner (S). 

Figure 1. Milgram experiment setup.

The setup, seen in Figure 1, involved the teacher posing questions to the learner, with incorrect responses resulting in purported electric shocks administered by the teacher. These shocks escalated in intensity, with the learner feigning distress and discomfort.
What emerged from this study was profoundly unsettling: individuals, when placed under the sway of authority, demonstrated a startling willingness to inflict harm. Participants, despite their initial reluctance, proceeded to administer shocks, some purportedly reaching levels of potential fatality. While the shocks were simulated, the implications were profound, revealing the extent to which authority figures can shape our thoughts and actions, coercing us into behaviors we might otherwise consider unthinkable.

Stanford prison experiment

Another landmark study that vividly illustrates the sway of the social environment is the Stanford prison experiment conducted in 1971. In this simulation, a cohort of college men was partitioned into two groups: prisoners and guards. What transpired within the confines of this simulated prison environment was both illuminating and disconcerting.
Remarkably swiftly, the guards assumed authoritarian roles, exhibiting behaviors that veered into aggression and abuse. While not all guards succumbed to this behavior, a significant proportion did, wielding their newfound power with alarming ease. Conversely, the prisoners swiftly adopted a passive and submissive demeanor; their resistance largely quelled in the face of the guards' dominance.

This rapid transformation underscores the profound impact of social roles, demonstrating how individuals, when thrust into specific roles within a structured social context, can quickly adopt behaviors that conform to the expectations associated with those roles.

Jane Elliot's blue eyes, brown eyes exercise 

One of the most compelling demonstrations of the impact of social conditioning is the exercise conducted by teacher Jane Elliott in the aftermath of Martin Luther King Jr.'s assassination, an experiment often referred to as the "blue eyes, brown eyes" exercise. This exercise, conducted over two days, ingeniously exposed the malleability of attitudes and behaviors in response to social messaging.

On the first day, Elliott segregated her students based on eye color, with blue-eyed individuals designated as superior and brown-eyed individuals as inferior. Through subtle reinforcement of this hierarchy, she observed a rapid transformation in behavior: the "superior" group performed better on tests and exhibited discriminatory behavior towards their "inferior" peers. Remarkably, these attitudes and behaviors reversed on the second day when the roles were switched.

This experiment powerfully illustrates how societal messages and roles shape our cognition, behavior, and even academic performance. It highlights the impact of social environments on brain development and reinforces the notion that individual beliefs and attitudes can be strongly influenced by external factors.

These studies collectively underscore the interplay between individual psychology and the broader social context. They serve as reminders of the pervasive influence wielded by authority figures, societal roles, and messaging, shedding light on the mechanisms through which discrimination is perpetuated and its profound effects on individuals' lives, cognition, and behaviors.

Defining Racism

Racism, at its core, manifests as a social system underpinned by an ideology that categorizes one race as superior and others as inferior. Within our society, this hierarchy positions non-white individuals as inferior or as the "other," with different races invariably compared to the standard of whiteness. Even within the framework of cultural competency, which aims to enhance outcomes among minority populations, there persists a subtle implication of a dominant culture against which others are measured—a phenomenon closely linked to ethnocentrism, wherein one's own culture is held as the standard.

While it's natural to notice and compare cultural differences when encountering diverse communities, this tendency also reflects the influence of our socialization within a particular cultural milieu. As the famous anthropologist Ralph Linton noted, "The last thing a fish would notice would be the water"—our cultural norms and values are so ingrained that they often go unnoticed. These differing socialization processes give rise to cultural diversity and disparities within society.

Racism, however, extends beyond mere individual beliefs or behaviors; it encapsulates an overarching ideology that permeates various levels of societal organization. It manifests in multiple forms, ranging from interpersonal interactions to institutional practices and societal structures. This systemic nature of racism profoundly shapes the allocation of resources within society, influencing everything from laws and policies to workplace dynamics and individual interactions. Its influence is pervasive, impacting both explicit actions and the often unconscious biases that shape our thoughts and behaviors.

Historical Roots

Examining the historical underpinnings of racism reveals a fixation on physical characteristics as markers of racial difference. Scientists of the past endeavored to categorize humans based on these perceived differences, resulting in myriad classifications of race—a testament to the inherently subjective nature of such categorizations.

Racism, in its historical context, emerged as a mechanism to justify the exploitation of certain groups, particularly through the institution of slavery. By labeling these groups as inherently inferior, proponents of racism sought to rationalize their deprivation of basic rights and privileges. This process of othering contributes to the dehumanization of marginalized communities, effectively rendering them as less than equal in the eyes of the dominant group.

Scientific advancements have since debunked the notion of race as a genetically determined trait. Instead, research has underscored the vast genetic diversity within and between racial groups, highlighting the fallacy of using race as a biological marker of inherent difference. Despite this scientific understanding, the social significance of race remains potent, shaping societal structures and interactions in profound ways.

Health Disparities by Race

When examining health disparities by race, it's crucial to distinguish between health disparities and health inequities. A health disparity simply refers to differences in health status between groups, with race being one of the many social factors considered. These differences are identified through research that controls for individual factors and seeks to explain potential variables that may contribute to variations in health outcomes. Our social location—comprising both ascribed and achieved statuses—plays a pivotal role in shaping our experiences within society. Ascribed statuses are those inherent from birth, while achieved statuses are acquired over time through various accomplishments, such as educational attainment. These statuses collectively form our social location and serve as our starting points within societal hierarchies and organizations.

When investigating health disparities, the focus shifts from individual characteristics to group differences, aiming to understand the broader societal factors at play. It's not about assuming differences based on race but rather about identifying significant variations in health outcomes and exploring the underlying social determinants that may contribute to these differences. In essence, it's about contextualizing health outcomes within the broader socio-political landscape to discern their implications and inform targeted interventions aimed at promoting health equity for all.

Health inequities, unlike disparities, arise from systemic factors such as policies, practices, and access to resources, resulting in unjust and preventable differences in health outcomes. In the field of medical sociology, we often examine "amenable deaths" or excess deaths—those that could have been prevented with adequate resources and interventions. We can discern how legislative and systemic changes affect health outcomes by examining policies and comparing different regions.

These inequities manifest across various health indicators, including life expectancy, infant mortality, premature births, overall morbidity and mortality, and disparities related to COVID-19 infection and mortality rates. Even among populations with high socioeconomic status and healthy behaviors, such as non-smoking and proper nutrition, racial disparities persist, particularly in outcomes like premature birth rates.

The COVID-19 pandemic has starkly highlighted the intersection of health disparities and social determinants of health. Overlaid upon existing health conditions like COPD, diabetes, and obesity—which are more prevalent in marginalized communities—the pandemic has exacerbated health inequities. Social and economic factors such as poverty, stress, and social isolation further compound these disparities, creating a complex web of interconnected influences on health outcomes.

These disparities are not evenly distributed across populations but are concentrated in specific communities and neighborhoods with higher social and economic disadvantage levels. The confluence of these factors underscores the multifaceted nature of health inequities and the urgent need for comprehensive, multi-level interventions to address their root causes and promote health equity for all individuals and communities.

Mental Health Inequity

The persistence of mental health inequities is a concerning and disheartening reality, reflected in discussions and efforts within professional, scientific, and advocacy circles. In 2002, the Institute of Medicine issued a seminal report titled "Unequal Treatment," which documented the disparities in mental health outcomes by race. This report, alongside a wealth of prior research and longitudinal studies, has provided an extensive evidence base highlighting the significant differences in mental health experiences and outcomes that persist along racial lines.

While strides have been made in understanding and addressing mental health disparities, substantial gaps in data and research persist, hindering comprehensive efforts to tackle these issues effectively. Despite the accumulation of evidence, meaningful reductions in mental health disparities by race have yet to be realized, underscoring the complexity and resilience of these inequities.

The disparities in mental health treatment access and utilization among different racial and ethnic groups, as highlighted by SAMHSA surveys in 2020, are deeply troubling. The surveys showed that 69% of Black and 67% of Latinx adults were not receiving any mental health treatment if they were identified that they needed mental health treatment. In addition, 42% of Black and 44% of Latinx adults did not get any treatment for serious disorders. Also, 88% of Blacks and 89% of Latinx did not get any treatment for substance abuse disorders. White individuals had nearly twice the odds of receiving community-based mental health and substance use treatment, and that was four and a half times higher odds of receiving treatment for co-occurring disorders. The statistics reveal stark differences in treatment rates, with Black and Latinx individuals experiencing significant barriers to accessing mental health care compared to their White counterparts. These findings underscore the urgent need to address the systemic factors contributing to these disparities.

While race is a critical factor in understanding mental health inequities, it's essential to recognize that other intersecting identities, such as gender, gender identity, sexuality, disability status, and socioeconomic status, also play significant roles in shaping individuals' experiences of discrimination and access to care. Discrimination, whether based on race or other factors, creates social exclusion and can contribute to feelings of not belonging, exacerbating mental health disparities.

This broader lens allows us to understand mental health inequities as stemming from systemic factors embedded within various social institutions, including education, family, government, religion, and media. These institutions influence perceptions, attitudes, and behaviors collectively, contributing to social exclusion and disparities in mental health outcomes.

Addressing mental health disparities requires a comprehensive approach that recognizes the intersecting influences of race, identity, and social status. It entails dismantling systemic barriers, promoting inclusivity and belonging, and ensuring equitable access to culturally competent mental health care for all individuals. By addressing the root causes of mental health inequities, we can work towards building a more just and equitable society where everyone has the opportunity to thrive mentally and emotionally.

Social Determinants of Health

Now, let's delve into the realm of social determinants of health. These encompass various societal factors that operate at a level beyond the individual. At this juncture, our focus shifts to collective groupings underpinned by structural dynamics. When considering group statuses based on age, race, gender, disability, and education, we gain insights into the social underpinnings of health outcomes. These factors inform health disparities and serve as key social determinants.

Social determinants operate within the broader societal context and can manifest at various levels—whether at the neighborhood, city, or state level. This multifaceted environment provides diverse frameworks for understanding health disparities. Key among these determinants are issues such as food insecurity, housing instability, and socioeconomic status, which encompass factors like income, employment, and wealth. Additionally, community infrastructure—including transportation systems and sidewalks—plays a vital role in shaping access to healthcare and overall well-being.

Furthermore, the quality and accessibility of education, insurance coverage, and access to care are potential barriers influencing health outcomes. Adverse childhood experiences, along with issues of race and racism, also contribute significantly to health disparities.

Levels of Racism

There are three levels of racism: interpersonal, institutional, and cultural, which correspond to the micro, meso, and macro levels, respectively. The interpersonal level, specifically discrimination, receives the most attention in research. In the United States, our culture tends to prioritize individuality over collectivism. Consequently, studies often examine the experiences of individuals facing discrimination in various social settings, such as at home, school, work, or in the community.

Interpersonal Level

The interpersonal level of racism and discrimination is the most extensively studied, reflecting the individual-focused nature of American culture. Research in this area examines the experiences of discrimination on a one-to-one or one-to-many basis, occurring across various settings such as home, school, work, and community. Meta-analyses, which compile and analyze numerous studies, reveal that individual experiences of discrimination are associated with an increased risk of major mental disorders, lower life satisfaction, and diminished self-esteem. This highlights the interconnection between discrimination and mental health outcomes, underscoring the importance of considering broader contextual factors within the behavioral health fields.

Furthermore, experiences of discrimination can precipitate personality changes, such as heightened neuroticism, over time. This association persists even when accounting for individual factors, emphasizing the independent impact of discrimination experiences. Importantly, these negative effects accumulate over the life course, suggesting a compounding effect with prolonged exposure to discrimination.

Moreover, discrimination's impact can extend beyond the individual experiencing it, affecting others vicariously. For instance, witnessing a caregiver endure discrimination can evoke a response in individuals, influencing their mental health as well. This highlights the pervasive and far-reaching consequences of discrimination on both the body and mind, highlighting the urgent need to address systemic inequities to mitigate its detrimental effects.

Experiencing discrimination

Let’s talk about experiencing discrimination. Prejudice is making assumptions based on race. Discrimination encompasses actions stemming from prejudice, such as microaggressions, profiling, and stereotyping. Research suggests that a significant proportion of ethnic minorities—between 26 and 35%—have encountered discrimination, which correlates with adverse mental health outcomes. These include emotional distress, post-traumatic stress disorder (PTSD), depression, anxiety, lowered self-esteem, and substance misuse. Moreover, discrimination is associated with adverse physical health outcomes, including high blood pressure, high body-mass index, poor overall health, and risky behaviors among adolescents.

Coping with social stressors like discrimination can lead to various coping strategies, some of which may have deleterious effects on health. Recognizing the link between social experiences and health outcomes is crucial in addressing the well-being of affected individuals.

Experiences of discrimination vary widely and affect diverse populations differently. Black and Latinx individuals tend to experience higher levels of discrimination compared to White or mixed-race Latinx individuals. This correlation often follows a socioeconomic gradient, similar to health outcomes. The significance of skin tone as a social determinant of discrimination underscores its arbitrary yet potent influence on individuals' experiences.

The stereotype of Asian Americans as a model minority can obscure disparities in mental health within this population. Despite the stereotype of high achievement, Asian adolescents report significant levels of discrimination, exacerbated by events like the COVID-19 pandemic and media-promoted stereotypes.

Meta-analyses demonstrate that experiences of racism are associated with an increased risk of traumatic stress symptoms, demonstrate the importance of acknowledging and addressing discrimination's impact on mental health. Incorporating this knowledge into practice can enhance support for individuals affected by discrimination, even if they do not explicitly raise the issue.

Impact on children

The impact of racism on children is significant, with both direct and vicarious experiences resulting in twice the risk of developing mental health problems such as anxiety, depression, suicide risk, and low self-esteem. Addressing this issue through interventions in education and media could substantially reduce this heightened risk and positively influence children's well-being and development.

Persistent experiences of racism can also significantly impact children's socioemotional and cognitive development. Studies have shown that children exposed to ongoing racism are twice as likely to experience sleep problems, which can adversely affect their school performance. 

Research indicates that racism affects parenting styles and caregiver mental health, leading to a twofold increase in preterm births and disproportionately high rates of maternal mortality. Black women are 3.3 times more likely to experience maternal mortality than white women, and American Indian/Alaska Native women are 2.4 times more likely to experience maternal mortality.

Role of unconscious bias

As discussions around racism become more prevalent in society, it's critical to address the concept of unconscious bias. This form of bias operates implicitly and outside conscious awareness, making individuals unaware of its influence. Despite not identifying with discriminatory behavior, unconscious bias can significantly impact the quality of care provided, particularly in healthcare settings.

Evidence shows distinct racial disparities in psychiatric diagnoses, highlighting the pervasive nature of unconscious bias. For instance, studies reveal that Latinos are more frequently diagnosed with anxiety, while African Americans are more commonly diagnosed with mood disorders, even when presenting identical symptoms. These discrepancies spur a need for greater awareness and mitigation of unconscious biases in clinical practice.

The intersection of racism with other social factors exacerbates its adverse effects on mental health outcomes. For instance, research indicates that Black veterans experience higher levels of pain, with discrimination experiences serving as a mediator for this association. In other words, the more discrimination they encounter, the worse their pain levels become, compounding the impact of racism on mental well-being.

Institutional Level

At the institutional level, the focus shifts to federal and local policies and social systems that disproportionately impact certain groups. Unlike individual or interpersonal racism, structural racism is rooted in power structures that extend beyond individual actions.

Structural factors, such as those observed at the community level, encompass the social determinants of health. These conditions represent inherent characteristics of society itself, including aspects like access to resources, economic opportunities, and social support networks.

Structural racism

Structural racism, as defined by the Aspen Institute, describes “a system in which public policies, institutional practices, cultural representations, and other norms work in various, often reinforcing ways to perpetuate racial group inequity.” This concept encompasses the historical and cultural dimensions that have allowed privileges linked to whiteness to persist over time while also perpetuating disadvantages associated with race. It's important to acknowledge that social determinants can affect various populations, including white communities, and that privileges associated with whiteness do not always translate to universal benefits. Discrimination can occur across multiple social statuses, including gender, gender identity, age, and socioeconomic status, complicating the dynamics of privilege and disadvantage.

However, structural racism primarily examines differences in resource allocation and the social status assigned to minority racial groups. It refers to the existence of overarching societal structures that influence individual thoughts and attitudes, ultimately shaping access to mental health services.

Structural factors

Structural factors include: 

• Immigration policies
• Residential segregation (controlling for socioeconomic factors)
• Mass incarceration; relationship to adverse childhood experiences
• Institutional racism and sexism, historical and contemporary
• Neighborhood disadvantage, poverty, unemployment  
• Displacement and loss of culture/belonging
• Social capital and social cohesion
• Redlining (reduced investment); services (schools, hospitals); built environment

Structural factors encompass wide-ranging societal elements such as immigration policy, residential segregation (accounting for socioeconomic factors), mass incarceration (linked to adverse childhood experiences), and historical institutional racism and sexism. Neighborhood disadvantage, particularly displacement, significantly contributes to poor mental health outcomes, as does substance abuse and overdose rates within communities. Social capital and cohesion, indicative of community connectedness, also play pivotal roles. Redlining, a discriminatory practice barring minorities from mortgage access, which persisted from 1934 into the 1960s, further exacerbates disparities.

Delving deeper into these factors, anti-immigrant immigration policies can have profound psychological impacts on minority populations, fostering racialized exclusion and undermining individuals' sense of belonging. This sense of belonging holds paramount importance for mental health, rooted in our evolutionary history, where social ostracization posed grave survival risks. Thus, these examples underscore the profound influence of broader social environments on individual mental health.

Residential segregation, the spatial separation of individuals based on race within neighborhoods and communities, can be enforced by law or perpetuated through individual discriminatory practices. Examples include redlining, differential mortgage rates, and disparities in homeownership opportunities. The phenomenon extends to the relocation of workplaces from inner-city areas to suburban locales, contributing to mass unemployment and subsequent social upheaval. White flight, observed predominantly during the 1970s, 1980s, and 1990s, further exacerbated these trends, leading to the fragmentation of communities.

The historical context is key when understanding these dynamics. Laws and policies have systematically entrenched disparities in wealth and resource access, resulting in vastly different starting points for various racial groups in their pursuit of health and well-being. The repercussions of such disparities, compounded over time, manifest in enduring social and economic inequalities.  Recovery from such setbacks, compounded by the profound mental and physical health impacts of unemployment and poverty, often spans generations and hinges on policy reform.

Empirical research underscores the significance of residential segregation, revealing its substantial predictive power. Studies suggest that eliminating residential segregation could markedly influence socioeconomic indicators, potentially reducing single motherhood rates by two-thirds among different racial groups. These findings demonstrate the impact of historical and systemic factors on contemporary societal disparities and highlight the imperative of addressing structural inequities to foster meaningful change.

The phenomenon of incarceration reflects systemic inequalities, with Black and Latinx populations disproportionately represented within the criminal justice system. As prisons increasingly assume roles as mental health care providers, the ramifications extend beyond incarceration itself. Individuals with a history of arrest are more likely to experience major depressive disorder, while aggressive policing correlates with declines in mental health. These circumstances can contribute to adverse childhood experiences, further compounding mental health risks, particularly within minority populations already burdened by structural inequities.

Neighborhood disadvantage amplifies these disparities, serving as a microcosm of broader societal injustices. Areas characterized by concentrated poverty exhibit heightened levels of social stress and safety concerns across multiple dimensions, encompassing physical, chemical, and psychosocial domains. The ripple effects are profound and include diminished property values, disinvestment, and shifts in local commerce, such as the transformation of essential services like restaurants and grocery stores into establishments that may pose health risks, such as tobacco shops. This economic decline perpetuates a cycle of deprivation, increasing challenges faced by residents and deepening health inequities within marginalized communities.

Socioeconomic factors play a significant role in shaping disparities, with historical practices like redlining significantly impacting the wealth accumulation of different demographic groups. Whites, for instance, have a net worth ten times higher than their counterparts. The enduring legacy of social exclusion perpetuates intergenerational wealth disparities, underscoring the need to challenge ingrained assumptions at the individual level while acknowledging this contextual backdrop.

It's important to recognize that structural inequities affect all demographics, with consequences reverberating throughout society. Stereotyping and stigmatization, exemplified by the rejection of initiatives like the Affordable Care Act, exacerbate mortality rates and hinder access to preventive care, even among privileged groups.

Developing structural competence is paramount in navigating these complexities. It entails discerning how upstream social determinants of mental health influence downstream clinical outcomes, illuminating the pervasive impact of historical injustices. For instance, the pathologization of normal responses to trauma, such as the portrayal of the desire to escape slavery as a disease, has entrenched systemic racism and biased diagnostic practices, perpetuating disparities across generations.

Recognizing the limitations of existing classifications and diagnoses is essential, as they often fail to capture the systemic factors underpinning mental illness, underscoring the imperative for a more holistic understanding of mental health within its broader sociohistorical context.

Cultural Level

At the cultural level, pervasive stereotypes perpetuated through media and societal norms can profoundly impact individuals' self-esteem and sense of identity. The looming threat of being stereotyped or subjected to discriminatory treatment can impede effective communication with healthcare providers, exacerbating disparities in access to care. While not universally experienced, these cultural phenomena reflect deeply ingrained societal ideologies and have far-reaching implications, influencing policy decisions and shaping interpersonal interactions. Derogatory terms and discriminatory practices underscore the harmful consequences of cultural stereotypes, as evidenced by the stigmatization experienced during the COVID-19 pandemic. 

Moreover, emerging research in epigenetics sheds light on how interpersonal and structural racism can manifest in physiological changes, transcending generations. Traumatic experiences and environmental factors can modulate gene expression, illustrating the intergenerational impact of social environments on physical health. Consider your grandmother's social environment: Did she face poverty, discrimination, or domestic violence? These stressors can leave a lasting imprint, affecting her and subsequent generations. Additionally, there are immunological implications; stress can impact the immune system, compounding the effects across time.

Fortunately, there are protective factors at play. Social support, community cohesion, religious or spiritual practices, and grassroots organizing can all mitigate the impact of discrimination. While they may not eliminate its effects entirely, these factors contribute to positive self-perception and facilitate meaningful social connections, fostering resilience in the face of adversity.

Policy Recommendations

As we delve into actionable recommendations, let's reflect on our sociological exploration. From the outset, we acknowledge that mental health conditions manifest disparately across populations, shaped by social and historical contexts. Our journey led us to confront structural racism—a pervasive force that continues to influence societal structures.

To address this, we advocate for structural competence—a deep understanding of how systemic factors influence individual interactions. Consider, for instance, a clinician encountering a patient who exhibits signs of distress. Understanding the broader social context—such as the impact of discrimination—can profoundly alter the approach to care, fostering empathy and trust.

At the systemic level, alongside policy reforms, we urge increased research into the impact of racism on psychiatric care and disorders, particularly among minority populations. For instance, exploring how discriminatory practices may skew diagnoses, such as Latinos being diagnosed with anxiety more frequently than African Americans for the same symptoms, is imperative.

To effect change, we propose diversifying the recruitment and mentorship of clinicians, ensuring that mental health services are accessible and culturally competent. This might involve advocating for essential services like interpreters, which are crucial for effective communication in diverse communities. Integrating structural competency and anti-racist principles into educational curricula and cultural competency training is critical. These measures are crucial for fostering equitable mental health care and combating the insidious effects of structural racism.

Practice Recommendations

At the clinical treatment level, psychologists and psychiatrists play a key role in addressing collective trauma and understanding how external factors impact individuals. Increasing awareness and acknowledging the influence of systemic issues on mental health, as well as the fact that racism exists everywhere, is a vital first step. Taking an honest inventory of one's social environment and applying a racial equity lens can guide practitioners in providing more inclusive and effective care. 

Recognizing the impact of societal and historical factors on psychology, genetics, behavior, and mental health systems is essential. It's not just about understanding the psychological effects but also acknowledging the physiological toll—such as increased cortisol production and accelerated physical deterioration—that racism can induce.

By acknowledging these systemic issues, clinicians can engage in constructive conversations with their patients and communities, fostering awareness and understanding. They may also choose to advocate for change at the policy level or become involved in community initiatives.

While addressing racism in mental health care may present challenges, it also offers an opportunity for personal growth and professional development. Practitioners who have experienced racism firsthand may bring valuable insights to their work, enhancing their ability to provide empathetic and culturally competent care.

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Editor's Note: This text-based course is an edited transcript of the webinar, Providing Behavioral Health Treatment to LGBTQ+ Populations: Introductory Ethical and Clinical Considerations, presented by Andrew Arriaga, PsyD.

Learning Outcomes

After this course, participants will be able to:

• Identify key terms, concepts, and empirical findings relevant to the understanding of LGBTQ+ people and their experiences.
• Identify common issues often reported by LGBTQ+ people in psychotherapy.
• Identify therapeutic challenges that may arise in psychotherapy with LGBTQ+ people.

Risks and Limitations

Today, I’d like to begin by discussing some of the risks and limitations we face. First, it’s essential to explore individual and cultural considerations before pursuing any treatment plans or interventions. Much of this is likely covered in your training—whether through graduate programs or hands-on clinical work—but these factors should always be carefully examined, often with supervision, to address potential concerns ahead of time.

The availability of gender-affirming therapeutic or medical support can vary widely depending on agency policies, local laws, and federal guidelines. As many of you are probably aware, gender-affirming care laws differ significantly across the United States. Some of what we discuss today may not directly apply to your specific region. However, that doesn’t lessen the importance of these concepts. Laws and federal guidelines are constantly evolving, so it’s critical to stay informed. Continuing education and supervision are highly recommended when working with LGBTQ+ populations. For some, this is a core focus in their work—particularly in behavioral health—but others may not have had as much exposure to these communities in their training or practice.

In light of this, it’s always beneficial to seek out further courses, like this one, and connect with supervisors who can offer broader perspectives and open up space for discussion. This approach is invaluable when serving populations with whom you may have limited familiarity. Since this is an introductory course, we won’t be able to dive deeply into all the health disparities and interventions across the lifespan for LGBTQ+ individuals. I’m sure many of you anticipated this, given the nature of the course, but it’s worth reiterating. Hopefully, in the future, I’ll have the opportunity to return, and we can take a deeper dive into these disparities and the interventions designed to address them. As you move forward from this course, keep in mind the importance of continued education and supervision. These will ensure you develop a thorough understanding of the health disparities LGBTQ+ individuals face and the appropriate interventions for supporting them in clinical settings.

Ethics Codes

As you know, behavioral health providers come from diverse training backgrounds, so many of us have encountered some or all of these codes in one way or another throughout our education. I strongly encourage you to always refer back to your specific ethical code when faced with ethical questions or decisions. While we all generally receive training grounded in similar ethical principles, there may be nuanced differences depending on the field in which you work. 

Below are links to Ethics Codes for some of the major behavioral health professions. Please ensure you always refer to your own ethical code.

• AAMFT: https://www.aamft.org/Legal_Ethics/Code_of_Ethics.aspx 
• ACA: https://www.counseling.org/resources/aca-code-of-ethics.pdf
• APA: https://www.apa.org/ethics/code 
• NBCC: https://nbcc.org/assets/ethics/nbcccodeofethics.pdf
• NAADAC: https://www.naadac.org/code-of-ethics
• NASW: https://www.socialworkers.org/About/Ethics/Code-of-Ethics/Code-of-Ethics-English

Ethical Considerations

I’d like to begin by focusing on some general ethical considerations when working with LGBTQ+ individuals. As I’ve mentioned, ethical codes across behavioral health professions share commonalities, and many of us are familiar with at least a few of them. These codes typically require that, as professionals, we remain competent in serving a diverse range of clients, regardless of specific backgrounds. This applies not only to LGBTQ+ individuals but to all clients we encounter. It’s a vital point to keep in mind.

It’s natural to feel overwhelmed when faced with clinical situations that are unfamiliar or outside our comfort zones. However, a key ethical consideration is recognizing that our role as behavioral health professionals is to hold space for clients from all walks of life. We have the foundational skills to do this. So, if you're considering working more with LGBTQ+ populations but feel uncertain about your level of competence or confidence, I encourage you to remember that these ethical principles are already a part of your professional training.

That said, we also acknowledge that working with LGBTQ+ clients can be challenging for clinicians who may hold biases or discomfort with certain identities. This issue isn’t limited to LGBTQ+ clients; it can also apply to individuals from different religious, racial, or ethnic backgrounds. However, I always remind colleagues that the core of this work is about adhering to the same ethical standards you would apply to any client. So, whenever you find yourself making clinical decisions, always refer back to the ethical codes of your profession.

Important Ethical Concepts

I’d like to focus on a few ethical concepts that I find particularly important when working with LGBTQ+ clients. Many of these terms, if not all, will likely be familiar to you, but let’s explore them in this context.

First, autonomy. It’s crucial to remember that, just like with any client, LGBTQ+ individuals know themselves best. Gatekeeping care can be a significant concern, especially when clients feel misunderstood or sense that a clinician is steering them in a direction misaligned with their experiences. At the end of the day, we must trust that our clients understand their own needs.

Next, beneficence and nonmaleficence—core values we’re all familiar with in behavioral health. These principles remind us to do right by our clients, to help them navigate challenges in ways that are both productive and safe. Above all, we must ensure we’re not causing harm. When facing ethical dilemmas, it can help to simplify the situation: Am I doing everything within my ability to serve this person? Is there any risk that my actions could harm them? Avoiding decisions that could cause harm is especially critical when working with LGBTQ+ individuals, as there are often additional nuances to consider, which we’ll dive into later.

Fidelity and veracity—respecting others' rights and dignity—may seem straightforward, but they are fundamental to our work. This includes ensuring confidentiality and creating a safe space for LGBTQ+ clients, whether they are currently identifying as such or not. It’s essential that they feel comfortable exploring their experiences and unique challenges in an environment that honors their dignity and listens without judgment.

Lastly, justice. A significant aspect of working with LGBTQ+ individuals often revolves around social justice. Some of us are engaged in anti-racist training, social equity efforts, or advocacy work within our communities, and these elements can also shape our clinical practice. For LGBTQ+ communities, social justice concerns frequently arise, given the ongoing legal and social barriers that impact access to care and equality. Recognizing and supporting clients on their journey toward justice, both in and outside of the therapy room, is invaluable. Our role as clinicians, from an ethical standpoint, is to align with and support those efforts, recognizing the broader social and legal issues that continue to affect these populations.

Key Terms

Let’s dive into some key terms and concepts. Some may be familiar, and a few might feel quite straightforward, but it’s useful for all of us to refresh our understanding, especially as some of these terms carry nuances that differ from how they’re often used in everyday language.

• gender identity: This refers to how a person perceives themselves—as a man, a woman, both, neither, or somewhere along the spectrum. Essentially, it’s about how individuals define themselves and what they choose to call themselves. You may hear terms like cisgender man, transgender woman, non-binary, or agender, all of which relate to gender identity.
• gender expression: This differs from gender identity. Here’s where we start to get into the nuances of language, as these terms are often used interchangeably in everyday conversation. However, from a clinical and research standpoint, it’s important to distinguish between them. Gender expression refers to how people outwardly communicate their gender identity through behavior, clothing, hairstyles, voice, and overall presentation. For example, you might hear someone described as presenting masculinely, femininely, or with an androgynous expression. These terms reflect aspects of gender expression, rather than gender identity itself.
• anatomical sex: This refers to physical attributes such as external genitalia, sex chromosomes, gonads, hormones, and internal reproductive structures. These are typically the biological markers used to assign sex at birth, which leads us to the next term.
• sex assigned at birth: This is determined by a medical professional based on the visible physical characteristics of a newborn. Typically, this assessment is made by visual examination of external genitalia, such as assigning male if a baby is born with a penis. However, like gender, sex is a complex concept, and this visual method of assigning sex can sometimes oversimplify the biological variations that exist.
• sexual/romantic attraction: Generally, this refers to a person’s emotional or sexual attraction to people of the same or different genders. You may also encounter the term sexual orientation, which is often used interchangeably in this context. While these terms overlap in casual conversation and even in some clinical spaces, it’s helpful to clarify that we’re talking about attraction in both romantic and sexual senses here.

The Genderbread Person

I want to take a moment to introduce the "Genderbread Person." There have been many versions of this circulating for over a decade, but it's a useful tool in clinical work to highlight the differences between these terms and delve into the nuances. It helps explain to clients—whether they are LGBTQ+ or simply exploring their identities—how gender identity, gender expression, and sex assigned at birth can intersect and diverge in unique ways.

Figure 1. The Genderbread Person. Image Source: genderbread.org – CC Universal Public Domain Dedication

When I work with clients using the Genderbread Person, it can also be helpful for parents or family members in therapy, especially those with LGBTQ+ loved ones or those trying to become more supportive. I usually begin with gender identity, as we discussed earlier. This refers to a person’s internal sense of self—how they see themselves and what they prefer to be called. Terms like man, woman, and non-binary are often associated with gender identity.

Next, I move to gender expression. The key point here is that gender expression is how we outwardly communicate our internal identity to the world. Clothing plays a big role in this, but so do other personal choices in style and behavior. For instance, some might assume that identifying as a woman means you should wear dresses and makeup, but that’s simply not the case. If you prefer sweatpants and don’t like makeup, that’s perfectly valid. The takeaway here is that gender identity and expression don’t necessarily predict one another. A feminine man or a masculine woman, whether LGBTQ+ or not, is entirely possible. These are separate constructs, and understanding this is crucial for psychoeducation.

When we talk about anatomical sex, we’re shifting into the more medicalized terminology—terms like male, female, and intersex, which refer to physical characteristics. This leads into sex assigned at birth, where a newborn’s sex—often labeled as male or female— is assigned by a medical professional based on external genitalia. However, as we’ll discuss, this can be more complex, especially in cases of intersex individuals.

Now, an important distinction to make is between gender identity and sexual orientation. Sexual or romantic attraction to others has no bearing on one’s gender identity. For instance, if a cisgender man—someone assigned male at birth who identifies as a man—is attracted to both men and women, that has no direct connection to his gender identity. Attraction, whether sexual or romantic, exists as a separate construct.

This distinction is especially important because, in public discourse and media, there’s often confusion between gender identity and sexual orientation. Trans and gender-diverse individuals are frequently lumped together with queer people, which can blur the lines between these concepts. The Genderbread Person graphic highlights this beautifully, illustrating that identity, expression, sex, and orientation are distinct elements.

Understanding these concepts allows clients to gain clarity about their own experiences: Is this about my gender? How I present myself? Or is it about who I’m attracted to? Each is its own construct, and recognizing this helps break down confusion and fosters deeper self-awareness.

Additional Key Terms

Let’s go over some additional key terms. I’ve included these because, especially in work with younger people or those who are more comfortable discussing LGBTQ+ issues, you may encounter terms that are unfamiliar or used in shorthand. Some of these may seem elementary, and you’ve likely heard them many times before.

• heterosexual: Most of us are familiar with this term or the shorthand “straight” or “hetero.” It refers to someone who experiences sexual, romantic, or emotional attraction to people of a different gender. Historically, it’s been defined as attraction to the "opposite" gender, but since gender is now understood as a spectrum, we try to move away from that language and be more mindful of gender diversity.
• bisexual: This term, with shorthand “bi,” refers to a person who experiences sexual, romantic, or emotional attraction to their own gender as well as to others. Some may assume this means attraction to men and women only, but bisexuality can also include attraction to non-binary or agender individuals. So, defining bisexuality strictly as attraction to men and women is exclusionary. Instead, we acknowledge that it means attraction to the same gender and others.
• pansexual: Shorthand “pan,” refers to sexual, romantic, or emotional attraction to individuals regardless of their gender identity or sex assigned at birth. This broader concept of attraction extends beyond specific gender categories and can include an openness to many, or all, gender identities.
• aromantic and asexual: Often shortened to “aro” and “ace,” these terms are frequently heard together, especially when working with younger clients. Someone who identifies as aro-ace experiences little to no romantic or sexual attraction. However, it’s important to note that individuals on these spectrums may still experience some attraction but don’t feel the need to act on it in the way others might.
• intersex: This refers to individuals born with chromosomal or physiological variances, including ambiguous genitalia. Sex assigned at birth is often based solely on external genitalia, but as we know from biology, sex involves more than just what is visible at birth. Hormones, chromosomes, and reproductive structures all play a role in defining sex, and these factors may not always align with the assigned label. Intersex people exist, and their experiences are distinct from those of individuals assigned male or female at birth. There’s a broader ethical conversation about the practice of assigning sex at birth based on genitalia alone, but that’s a topic for another day.
• transgender: Shortened to “trans,” is a term you’ve likely heard in many contexts—whether in the news, schools, or clinical practice. It’s often used as an umbrella term to describe individuals whose gender identity does not align with their sex assigned at birth. For example, a transgender man is someone who was assigned female at birth but identifies and lives as a man. A transgender woman is someone assigned male at birth who identifies as a woman. It’s important to recognize that within the trans community, individuals may use more specific terms for themselves, such as trans man, trans woman, or trans girl. Some may even prefer not to use the term "trans" at all and simply identify as a man or a woman. Checking in with clients about the language they prefer is crucial.
• gender binary: This is the social system that assigns everyone to be raised as a boy or girl based on their sex assigned at birth. This rigid perspective of gender assumes that male and female are the only two options. However, we know that non-binary or genderqueer individuals exist—people who don’t identify strictly as male or female. Gender fluidity, which refers to a flexible range of gender expression and identity, can be confusing for some who aren’t used to thinking of gender as fluid.

It’s common to hear even more unfamiliar terms when working with younger individuals. It’s important to remember that, ultimately, the client’s view of their own identity and the language they prefer is what matters most—regardless of what you may have learned in a class or even here. While we’ve covered some typical terms for familiarity’s sake, it’s crucial to let our clients lead the way in how they identify and express themselves.

Some people may feel different on different days, choosing to express themselves in a variety of ways. For example, one day they may enjoy wearing dresses, and another day they may prefer a more masculine presentation with jeans and sneakers. This doesn’t necessarily reflect their gender identity but could simply be an expression of their fluid identity. With that said, the language around gender and sexual orientation is constantly evolving. It’s always important to follow the lead of your clients and ask directly if you’re unsure. Simple questions like “What would you like me to call you?” or “Do you have a preferred pronoun, name, or gender identity?” can make an LGBTQ+ client feel truly seen and heard.

Why is This Topic Important

Why is this topic important? I’m sure many of you could think of several reasons off the top of your head, but I’d like to highlight a few key ones that I’ve found particularly motivating in this field. These reasons underscore why we should be competent in this work—or at least work toward that goal.

As clinicians, we have an ethical duty to be prepared to serve individuals from all backgrounds. This means being aware of terms and concepts that are central to LGBTQ+ experiences, so we can create a welcoming and inclusive space for these clients. Familiarizing ourselves with these terms ensures that we are ethically prepared to support them.

Additionally, awareness of LGBTQ+ identities and the social issues within these communities continues to grow. You’ve probably noticed this yourself—there’s increasing visibility around queer and trans people. By “queer,” I’m referring to those who identify as sexual minorities, such as gay, lesbian, bisexual individuals, and more. As society becomes more knowledgeable, we often see an increase in the presentation of these identities in clinical spaces, as people feel more comfortable bringing these aspects of themselves into therapy.

LGBTQ+ individuals also face a unique set of interpersonal and intrapersonal stressors, which need to be carefully considered in clinical work. I’ll walk through some of these stressors and the theoretical background that explains why they exist. Because of these increased stressors, LGBTQ+ people continue to experience disproportionately higher rates of health and wellness disparities—far exceeding those of majority populations.

LGBTQ+ Identity Statistics

Let’s go over a few statistics about identity and where things stand today based on the most recent data. Analyses conducted by the Williams Institute, using 2020-2021 data from the Behavioral Risk Factor Surveillance System—a major study conducted most years—revealed some notable findings about identity. Even I was a bit surprised by some of these, but it's heartening to see these shifts.

For example, 36% of respondents in the Southern U.S. identified as LGBTQ+, making it the largest regional population compared to the Northeast, Midwest, and Western states. This was unexpected for me, as someone from the South and Texas, but it’s encouraging to see more openness in this region, especially considering the political and cultural challenges that LGBTQ+ people often face in the Southern United States.

Additionally, almost one in six adults aged 18 to 24 identify as members of the LGBTQ+ community. I was pleasantly surprised by this as well. Of course, there are often heated discussions around this statistic—questions like, "Why are more young people identifying this way? Is there a rise in people becoming queer or trans?" In my opinion, much of this can be attributed to increased social acceptance and visibility for Gen Z and Gen Alpha, leading to greater comfort in openly identifying as LGBTQ+.

As for state-level data, California has the largest number of LGBTQ+ adults, with about 1.5 million. It’s also worth noting that, currently, the U.S. Census does not include questions about sexual orientation or gender identity, despite various proposals over the years. As a result, we rely heavily on studies conducted by universities and research institutes to provide this data.

Minority Stress Theory

Let’s start with a bit of theory. Ilan Meyer’s Minority Stress Theory is a framework you’ll often encounter in research and work with LGBTQ+ people. It posits that these populations face unique intra- and interpersonal stressors, which contribute to poorer health and wellness outcomes, beyond what is typically experienced by majority populations. When I talk about intrapersonal and interpersonal stressors, I’m referring to the stress that arises from interactions with others or from being in negative environments.

Interpersonal stressors include experiences like discrimination, microaggressions at work, or being denied services. This can be explicit or policy-driven and doesn’t always involve direct one-on-one discrimination. Intrapersonal stress, on the other hand, may be less familiar, especially to those who haven’t struggled with issues like shame or identity. LGBTQ+ individuals often face stress from internal conflicts, fear, or confusion when acknowledging their identities.

One common form of intrapersonal stress is internalized phobia, where an LGBTQ+ person begins to internalize negative messages from transphobic or homophobic encounters and directs that negativity toward themselves. This internalized negativity can be profoundly impactful and is unique to these populations. Meyer’s theory has been foundational in LGBTQ+ health and wellness research and is the basis for thousands of studies. The theory has also expanded to include other aspects of identity that compound stress, such as race, ethnicity, or socioeconomic background. Staying informed on the latest research and theoretical perspectives is crucial for engaging in this work, even if you’re not reading research articles all the time. Checking in occasionally can be helpful.

LGBTQ+ Barriers to Care

LGBTQ+ individuals often face significant barriers to care, sometimes even before measurable health impacts arise. Many postpone or avoid medical or behavioral healthcare altogether—even when dealing with serious issues like infections, suicidal ideation, or distressing mental health problems.

There are several reasons why LGBTQ+ individuals may avoid care. A major one is the fear of having their gender-diverse or sexual minority identity pathologized. The outdated view that being transgender or homosexual is something “wrong” still lingers in some spaces. Until recently, homosexuality was classified as a disorder in the DSM, and gender dysphoria remains in the current edition, largely for insurance purposes. Despite this, many still fear going into a hospital or therapy setting and being treated as though something is inherently wrong with them.

There are also more direct concerns, such as discrimination by healthcare providers. This discrimination doesn’t always manifest overtly; it can come in the form of microaggressions or comments rooted in heteronormative or cisnormative beliefs. Finally, past negative experiences with healthcare providers can deter people from seeking care. If a doctor made them uncomfortable when they disclosed their sexual orientation, it can discourage them from returning to that space—or to any medical provider. It’s common for clients to ask for lists of LGBTQ+-affirming providers, emphasizing their need to feel understood and cared for in the same way as cisgender and heterosexual individuals.

LGBTQ+ Health Disparities

Minority Stress Theory has sparked extensive research into why LGBTQ+ individuals face significant health disparities. Several large studies have shed light on these disparities. For example, the All of Us research project found that LGBTQ+ adults are more likely to experience tobacco use disorder than their heterosexual and cisgender counterparts. This pattern extends to other substances as well, with research showing elevated rates of alcohol and substance use among queer and trans people. The link between stress and tobacco use, in particular, highlights how these disparities may reflect the increased stress faced by these populations.

On a more positive note, a study by The Trevor Project found that higher levels of social support are associated with fewer suicide attempts among LGBTQ+ youth. This finding reminds us that social support—whether from family, friends, or school—can be protective against suicidality.

However, challenges remain. One in four transgender adults reported experiencing an issue with their insurance related to being transgender in the past year. As my previous work in the Gender Health Department with Kaiser Permanente illustrated, insurance coverage for gender-affirming care remains a significant barrier. While there’s a perception that greater visibility for trans issues means more equality, this is not always the case.

A Myriad of Presenting Issues

In therapy, queer and trans individuals often present with many of the same issues as other clients: depression, anxiety, social isolation, and marginalization. While these issues can affect anyone, the factors behind them—such as rejection by family or the broader community—can look different for LGBTQ+ individuals.

Family conflict, for example, is common across the board but may stem from lack of acceptance of a client’s identity. For clinicians experienced in addressing family conflict, those skills are just as valuable when working with LGBTQ+ clients. Similarly, issues like substance abuse and addiction are prominent among certain LGBTQ+ subcommunities, and licensed addiction specialists can bring their expertise to this work.

More severe concerns, such as complex trauma or physical and sexual violence, are also common. Transgender individuals, especially trans women of color, are often targets of violence due to prejudice and political discourse around their identities. While trauma can affect anyone, the targeted nature of violence against transgender people is a stark reality.

Finally, LGBTQ+ individuals may present with psychosis, though there’s no unique connection between this condition and their identity. Like all clients, they may face psychosis for a variety of reasons.

Other Unique Issues

There are some unique issues to consider when working with LGBTQ+ individuals. One common issue I’ve encountered is the questioning of identity. Someone may come to therapy without identifying under the LGBTQ+ umbrella, but they’re trying to figure out, “What does this mean for me? Am I gay? Am I transgender? Am I non-binary or sexually fluid?” You’ll hear all sorts of terms in these situations, and it can be a very confusing journey for the client. This is where psychoeducation around language, gender, sexual orientation, and birth sex can be incredibly valuable in helping clients clarify these questions.

Coming out, or informing others about one’s sexual orientation or gender identity, is a unique issue within the LGBTQ+ community. While not entirely exclusive to this group—people may “come out” regarding political ideologies or religious beliefs—coming out as LGBTQ+ often brings its own set of challenges. Even someone who feels secure in their identity might face difficulties when entering new spaces, especially if they haven’t had to come out in a while. The process of coming out is ongoing, as long as we are meeting new people, and the environment can impact whether it feels safe to do so.

Gender dysphoria is another major issue for individuals exploring their gender identity. This disconnect between one’s gender identity and their sex assigned at birth, or societal expectations based on appearance, can manifest as discomfort with secondary sex characteristics, pronouns, or even the name being used for them. Gender dysphoria is complex, and working through it often requires additional training and supervision to ensure you’re guiding clients in a helpful, non-harmful way.

Internalized homophobia and transphobia, as mentioned earlier, can also be deeply challenging in therapy. Some clients may not even recognize that they are acting out this internalized negativity toward their own identity.

Pointed discrimination—whether in medical, educational, or workplace settings—can be another major issue. LGBTQ+ individuals may face systemic or interpersonal discrimination that others do not. Acknowledging these struggles helps clients feel seen and validated in their day-to-day challenges.

A particularly unique issue is the why behind identity. When there’s shame associated with a minority identity, people often ask themselves, “Why me? Why do I feel different from my heterosexual siblings? How did I end up like this?” While research continues to explore the predictors of LGBTQ+ identity, there’s still much uncertainty. Holding space for this uncertainty, especially when clients are grappling with shame, can be an important part of the therapeutic process. Acceptance can play a key role in this work.

Even for Clinicians, Issues Arise!

Even for us as clinicians, issues can arise in therapy. One common issue discussed in supervisory meetings is identity disclosure by the therapist. There are strong arguments on both sides of this, and it can depend on your therapeutic orientation, setting, and personal beliefs about how a therapist should show up in the room. There is no definitive answer, which is why it’s helpful to acknowledge that this is a complex issue for many clinicians.

This includes whether to disclose your sexual orientation, gender identity, or even the pronouns you use. These days, with the push toward transparency, many clinicians include their pronouns in email signatures. This is often done to signal to prospective LGBTQ+ clients that their identities will be respected. However, some therapists believe that providing personal information could overshadow the client’s concerns or pressure them to be open about their own identity. If you’ve struggled with this, you’re not alone—it’s a topic of ongoing discourse in the field.

So What If I Make a Mistake?

What happens if you make a mistake? If you use the wrong pronouns, the wrong name, or an outdated term for someone’s sexual orientation?

The first thing to do is apologize. Acknowledge the mistake: “I’m so sorry, I didn’t use your correct pronouns.” Then, correct yourself and move on. It’s important to avoid over-apologizing, as this can shift the burden onto the client to comfort you. Even though the mistake was well-intentioned, repeated apologies can make the client feel like they need to take care of the therapist, when they’re the ones who were slighted.

It’s also important to keep updated on preferred terms, pronouns, and names, especially if you have a large caseload. Clients may experiment with different names or pronouns throughout the course of therapy, and that’s okay. Be patient with yourself—it does get easier with time. While some may feel frustrated by this fluidity, simplifying identity exploration in that way does a disservice to the complexity of the process.

If you work in a setting where medical charts or patient files are accessible to others—such as when working with adolescents—it’s important to be mindful of how you use pronouns and names. For example, if a client isn’t ready for their family to know about their identity, you may choose not to chart using the pronouns or name they use in session. The implications of when and where to use these terms are complex, but with practice and guidance, it becomes more manageable.

Case Study

All right, as we near the end, I’d like to present a case study for consideration. You’re halfway through your third session with Amos, a 16-year-old Mexican American who uses he/him pronouns, when he reveals that he’s been scratching himself deeply over the past week. When you ask why, he hesitantly admits that he’s trying to suppress “unnatural urges.” Eventually, he confides that he believes he’s developing a crush on a close male friend, but the thought terrifies him because he’s worried he might be gay. At this point, you also recall that during the intake, Amos’s mother expressed her desire to be informed if there were any safety concerns. So, my question is: How would you proceed with Amos, given what you now know about his self-harm, its potential link to his sexuality, and his mother’s request? I’m curious to hear your thoughts on possible first steps and how you might approach this.

I can imagine that you might have conflicting thoughts about how to handle this situation. Some of you might think, “I would consult my supervisor to talk this through before proceeding.” That’s completely understandable, as it’s not always easy to give an immediate response in cases like this.

I’ll give you a moment to think about it and share your approach if you have something in mind. Broadly speaking, I think the key here is to prioritize ethical and clinical considerations, focusing on protecting our clients from harm while providing the best possible care.

I don’t intend to provide a clear-cut answer because there isn’t one. How you approach this could vary depending on the nuances of the situation. For example, you might consider whether there’s a way to address the mother’s concerns without outing Amos or jeopardizing his trust. When working with teens, we often enter gray areas regarding confidentiality. Although Amos is 16, and his parents could access his charts in most states, navigating this ethically while maintaining the therapeutic relationship is critical.

This is a common ethical dilemma, particularly when working with younger clients. It requires careful thought—sometimes what seems like the obvious answer, such as disclosing everything to the parent, may not be the best approach. There are many ways this could play out, and each has its own set of considerations.

Limitations

Now, let’s consider some limitations when working with LGBTQ+ clients. It’s important to remember that queer and trans identities are not monolithic. No two LGBTQ+ individuals are the same, just as no two straight or cisgender individuals are the same. So, even if you’ve worked with a trans client before, it doesn’t mean the next trans client will share the same experiences. There may be overlap, but each person’s story is unique, and we must approach them as such. As cultural climates shift, so do language norms. It’s essential to stay current with the language your clients use to describe themselves and their identities. Additionally, it’s crucial to consider intersecting identities before making assumptions. For example, a queer person of color may have different experiences than a white queer person. These intersections play a vital role in shaping the client’s experiences and how they present in therapy.

Finally, it’s worth noting that there are still no major federal efforts to gather comprehensive national data on LGBTQ+ experiences. This is a significant limitation in understanding the full scope of these communities. As data collection evolves, hopefully, we will have more accurate and refined insights into LGBTQ+ populations in the future.

Summary

In summary, we are ethically bound to be competent in serving clients from all backgrounds, including LGBTQ+ individuals. These populations face unique social stressors that contribute to the health and wellness issues often highlighted in research. While LGBTQ+ clients may present with similar issues as cisgender and heterosexual clients, we must remain aware of the unique challenges they face. Lastly, when ruptures occur with LGBTQ+ clients, it’s most effective to apologize, correct the mistake, and move forward.

References

American Psychological Association. (2017). Ethical principles of psychologists and code of conduct. https://www.apa.org/ethics/code

American Counseling Association. (2014). Code of ethics. https://www.counseling.org/resources/aca-code-of-ethics.pdf

Clay, R. A. (2015, April). Competence vs. conscience: ‘Conscience clause’ initiatives expand beyond psychology training into the practice arena. Monitor on Psychology. https://www.apa.org/monitor/2015/04/competence

Drescher, J., & Fadus, M. (2020). Issues arising in psychotherapy with lesbian, gay, bisexual, and transgender patients. FOCUS, 18(3), 262–267. https://doi.org/10.1176/appi.focus.20200001

Flores, A. R., & Conron, K. J. (2023). Adult LGBT population in the United States. https://williamsinstitute.law.ucla.edu/wp-content/uploads/LGBT-Adult-US-Pop-Dec-2023.pdf

Hailes, H. P., Ceccolini, C. J., Gutowski, E., & Liang, B. (2020). Ethical guidelines for social justice in psychology. Professional Psychology: Research and Practice, 2(1), 1-11. https://doi.org/10.1037/pro0000291

James, S. E., Herman, J. L., Rankin, S., Keisling, M., Mottet, L., & Anafi, M. (2016). The report of the 2015 U.S. transgender survey. National Center for Transgender Equality. https://doi.org/10.1038/064604a0

Leitch, J., & McGeough, B. L. (2023). A proposed stage model of LGBTQ people’s selection of and engagement with therapists. Families in Society, 104(3), 372–383. https://doi.org/10.1177/10443894221150667

McLemore, K. A. (2018). A minority stress perspective on transgender individuals’ experiences with misgendering. Stigma and Health, 3(1), 53–64. https://doi.org/10.1037/sah0000070

Meyer, I. H. (2003). Prejudice, social stress, and mental health in lesbian, gay, and bisexual populations: Conceptual issues and research evidence. Psychological Bulletin, 129(5), 674–697. https://doi.org/10.1037/0033-2909.129.5.674

Meyer, I. H. (2010). Identity, stress, and resilience in lesbians, gay men, and bisexuals of color. The Counseling Psychologist, 38(3), 442–454. https://doi.org/10.1177/0011000009351601

Tran, N. K., Lunn, M. R., Schulkey, C. E., Tesfaye, S., Nambiar, S., Chatterjee, S., Kozlowski, D., Lozano, P., Randal, F. T., Mo, Y., Qi, S., Hundertmark, E., Eastburn, C., Pho, A. T., Dastur, Z., Lubensky, M. E., Flentje, A., & Obedin-Maliver, J. (2023). Prevalence of 12 common health conditions in sexual and gender minority participants in the All of Us research program. JAMA Network Open, 6(7), e2324969. https://doi.org/10.1001/jamanetworkopen.2023.24969

The Trevor Project. (2022). 2022 National Survey on LGBTQ Youth Mental Health. https://www.thetrevorproject.org/survey-2022/

Additional Current References

Please Note: The following resources have been included for members to view additional resources associated with this topic area. These resources were not used by the presenter when creating this course. 

Chu, T. L. (A.), Treacy, A., Moore, E. W. G., Petrie, T. A., Albert, E., & Zhang, T. (2024). Intersectionality matters: Gender, race/ethnicity, and sport level differentiate perceived coach-created motivational climates and psychological needs. Sport, Exercise, and Performance Psychology, 13(1), 59–75. https://doi.org/10.1037/spy0000331

Dorrell, K. D., Benjamin, I., Dyar, C., Davila, J., & Feinstein, B. A. (2024). Minority stress and relationship satisfaction among bi+ individuals: The roles of partner gender and sexual orientation. Psychology of Sexual Orientation and Gender Diversity. Advance online publication. https://doi.org/10.1037/sgd0000711

Jeon, M. E., Udupa, N. S., Potter, M. R., Robison, M., Robertson, L., Rogers, M. L., & Joiner, T. E. (2024). Measurement invariance of the Depressive Symptom Inventory–Suicidality Scale across race, ethnicity, sexual orientation, and plurality of minoritized identities. Psychological Assessment. Advance online publication. https://doi.org/10.1037/pas0001306

Kim, H. J., Romanelli, M., & Fredriksen-Goldsen, K. (2024). Multidimensional social connectedness of sexual and gender minority midlife and older adults: Findings from the National Health, Aging, and Sexuality/Gender Study (NHAS). American Journal of Orthopsychiatry. Advance online publication. https://doi.org/10.1037/ort0000726

Lloyd, A., Granot, Y., Rovegno, E., Bazin, A., Bryant, A., & Richards, M. (2024). How schools can bolster belonging among Black lesbian, gay, bisexual, and queer youth. Translational Issues in Psychological Science. Advance online publication. https://doi.org/10.1037/tps0000039

This text-based course is an edited transcript of the webinar, Cultural Competency in Behavioral Health, presented by Sophie Nathenson, PhD.

Learning Outcomes

After this course, participants will be able to:

• Describe the concepts of cultural competency, cultural humility, and culturally competent behavioral healthcare.
• Explain three types of culturally based mental health disparities in the United States.
• Explain three evidenced-based approaches to improve health equity through culturally responsive care.

Risks and Limitations

There are a few notable risks and limitations in this presentation. It does not contain a comprehensive list of techniques or approaches for practicing culturally competent care, nor does it contain an inventory of cultural customs or attributes of any group. Any data presented is subject to change over time, population, and methods. The concepts in this presentation have differing and evolving definitions and applications across disciplines.

Introduction

I will start by introducing the sociological perspective, which I am trained in, and the social and cultural drivers of health and health disparities. Then, we'll move to defining cultural competency and related concepts. We will discuss the rationale for cultural competency in the behavioral health fields and for a systemic sociological view of cultural competency. Then, we will discuss the central components of cultural competency: knowledge, attitudes, awareness, and skills. To preface this, when defining cultural competency, we distinguish cultural competency from simply competency.

Defining Cultural Competency

Culture is a way of life. It includes a worldview, values (what is considered good or bad), beliefs (what is considered to be true), customs, and norms of behavior (the expected ways of behaving). Culture is very much related to the health and well-being of individuals. It is something to look at when it comes to health outcomes, including mental health. Competence can be defined as the ability to perform a task; when we talk about cultural competency, it includes knowledge as a foundation, awareness, attitudes, and skills to navigate the cultural concerns and problems that clients may present. Essentially, this means the ability to work with a variety of individuals across cultures, and be able to address cultural concerns, things that are culturally based or have to do with some of the bigger picture influences on that individual. 

Many times, we'll think of cultural competency not as simply the ability to perform a task or a knowledge base, a set of facts to be learned. Rather, more as qualities, some of which you may already have, and some of which can be developed over time in a continual process across the entire life course. Defining culturally competent care, it means clinicians can work with diverse clients, with a different cultural background, with variation in their responses based on this awareness of cultural differences.

A Sociological Perspective

To bring a sociological perspective to cultural competency, it is a slightly different perspective that training on specific cultural customs, and everything that makes this culture different from that culture. Instead, we are taking a bigger picture, societal of perspective. I am a medical sociologist, not a healthcare professional, and not a behavioral health professional. I'm coming from this perspective, where we're studying underlying social conditions that affect the health status of an entire group. This could be an entire society of people. And specifically, we're looking at inequalities; in sociology, as compared to psychology which studies individual differences, we are comparing group differences. This is not to say that people in a certain group are similar to each other. When we compare groups, we're looking at the health status of that group as a whole. If we see significant differences in life expectancy, physical illnesses, and mental health issues between one group versus another, what that tells us is that there may be something at a broader level within a community, within a society, that may be driving that inequality, or that difference.

When we look at the research on diverse populations, diverse is defined as non-dominant races. In the U.S., white individuals are the "dominant race." Looking at diverse populations and their perspectives, there's often a mention that being aware of systemic issues on the part of the clinician does impact the therapeutic relationship. We're going to zero in on that idea. Understanding some of the social context, even at the broadest country level and even on the global level--that knowledge and awareness impacts the relationship that you have with the client.

In our society, we have documented health disparities, and they've existed and persisted over a very long period of time. These inequities sparked the need for cultural competency. As our country becomes more diverse, as we get hip to the fact that culture does have an effect on health, these disparities and these inequities are deemed important to address. When looking at the whole health status of an entire population--again, that could be a country, county, a city, neighborhood, client base, patient population of a specific healthcare organization--if there are massive disparities, the health status of that entire group is going to go down. It causes decreases in the quality of life of many individuals. It also creates very poor metrics in terms of patient outcomes. It costs a lot more money. There are all sorts of negative impacts. Cultural competency, as a concept, is about creating more awareness and providing more knowledge to potentially reduce these disparities by providing better and more appropriate care (Phelan & Link, 2013).

From the sociological perspective, to wrap this up, we’re including the social context that goes beyond biomedical and psychological factors contributes to the manifestation of certain behaviors and disorders. When we include that social context in the mix, we acknowledge those other factors, and we can then address some of those factors that may be causing problems within a client. We'll talk more about that throughout this presentation.

Disparities Research

Taking a super broad brush of disparities research, I'll first say of the different social factors, age, race, gender, and socioeconomic status are the most studied regarding their effect on health outcomes. In cultural competency trainings and literature, there's often a focus primarily on race. Many different social factors are in the mix. We’ll look at some of the main kinds of domains of disparities, which are differences in any kind of health outcome; anything that we can measure that has to do with health. For example, Asian and Native American populations tend to have a higher prevalence of mental disorders. Black and Latinx populations tend to have a greater lifetime persistence of mental disorders.

In terms of access, minorities have fewer visits to mental healthcare services, are less likely to initially fill prescriptions for psychiatric disorders, and have higher dropout rates. This is controlling for other factors that may affect dropouts, such as language barriers, socioeconomic status, and the ability to pay for services. Tribal communities have less access and are less likely to access services. In terms of care quality, Black and Latinx individuals are less likely to receive guideline-based care, and Asians have a lower standard of care. These are very broad variables in terms of disparities, but an entire presentation could be dedicated to these disparities in a very wide variety of outcomes that have to do with mental health.

Mental Health Inequity

In terms of inequity, we differentiate between health disparities and health inequities. Health disparities are simply differences in health outcomes by group, but health inequities are disparities that are due to policy, system, practice, and access injustices. A lot of this has to do with a misdistribution of resources or a distribution that negatively affects certain groups more than others. It can be things like discrimination and racism at the individual or the system level. All of this is wrapped up into producing health inequities.

Looking at some data from the Substance Abuse and Mental Health Services Administration, SAMHSA, 69% of Black and 67% of Latinx adults were found to not be receiving any treatment for their mental health problems. 42% of Black adults and 44% of Latinx adults were not receiving treatment for serious psychiatric disorders. Shockingly, 88% of Black adults and 89% of Latinx adults were not receiving any treatment for substance abuse disorders. This paints a picture for you initially, at how different mental health access outcomes are. We can talk about why, like reverse engineering, as to what is going on at the system level to produce and contribute to this inequity. And how cultural competency can begin to address this, starting with the one-on-one level. Again, there are other social risk factors, such as gender, gender identity, sexuality, disability, and socioeconomic status, with inequities found when comparing those groups (Substance Abuse and Mental Health Services Administration, 2018).

This is important to consider that, again, while individuals in a certain social group or social status are not necessarily similar to each other in terms of individual similarities,  we're looking at the fact that these social statuses essentially lend themselves to differences in how your experience of the world is within a certain societ,y and that there are differences there.
Now, moving to the field of psychology and psychiatry. There are plenty of researchers, scholars, and people who practice in these fields that are calling for action taken to reduce disparities and to encourage cultural competency. This is not just something that is applied to healthcare, and it's also not new. We are at a point in society where public awareness of health disparities and health inequity has gone up significantly. Part of that is from events that happened during the pandemic. Everyone's at home tuning into the same news. Experiencing--at very different levels-- events at the societal level, and there is more awareness. When the concept of cultural competency entered the lexicon in healthcare 20, 30 years ago, it was not a new concept then either. It was just new on the scene in healthcare.

This goes back to 1970. "We are asking white psychiatrists to become increasingly aware of how their everyday practices continue to perpetuate institutional white racism in psychiatry." Looking at the sociological: "it means a significant reduction in economic barriers to psychiatric care, and it means relinquishing negative stereotypes" (Sabshin et al.,1970). Moving on to 1985, it's referred to as "an ethical obligation that cross-cultural skills are placed on a level of parity with other specialized therapeutic skills" (Ridley, 1985), part of the ethics of being a provider; to have the skills to serve a variety of clients and to be aware of the issues that may be disproportionately affecting these individuals. The APA (2002) says to "take precautions to ensure that their providers' potential biases, the boundaries of their competence, and the limitations of their expertise do not lead to, or condone unjust practices." In order to do these things and engage in actions according to these calls for action, there has to be first a knowledge of cultural differences in the social context, then trickling down to what that means for individual care and that therapeutic alliance.

Components of Cultural Competency

Now, we will go over the components of cultural competency and get more in-depth, especially with knowledge, the foundation, bringing in the social context of it all. The components of cultural competency are knowledge, attitudes, awareness, and skills. Number one: knowledge. I'm adding here an understanding of the context and the relevant issues. There are other definitions of the knowledge component of cultural competency that may be more specifically about knowing and learning about specific cultures. This is important. It can open your mind to the variation and the cultural implications to care and to all sorts of aspects of diagnosis and health philosophy, the subjective nature of different illnesses, the practices and the treatment, philosophies among different cultures. We don't want to build up this knowledge base so that we stereotype. That's part of the understanding of those cultural differences. We're building on that definition of knowledge of different cultures, to make sure that the knowledge domain includes inquiring about these cultural issues impacting the client and getting that information specific to that individual client (Sue et al., 2009).

Attitudes: this can be your attitude towards diversity in general. It can include empathy, non-judgment, and the therapeutic alliance wrapped up in that domain. Next is awareness: understanding one's own biases. Self-awareness is the practice of reflecting on where you're coming from and where your culture fits into the mix. Finally, we have skills. This can include assessment and your ability to use culturally sensitive interventions. All of these components exist at the personal, agency or organizational level, the community level, and the societal level. It's not just the one-on-one. It can be as broad as society in general; the knowledge, attitudes, awareness, and skills (Sue et al., 2009).

There are other key terms and terms to know, in part because culture can be very closely associated with ethnicity or race, and it's much broader than that. Ethnicity refers to cultural heritage and traditions: shared history, nationality, country of origin, religious affiliation, beliefs, and belonging to a particular faith. Race is a conglomeration of similar physical characteristics, but that's where we associate race within society. There's a very important distinction here where it could be seen as a biological set of differences, genetic differences, but we have the research to demonstrate that two people of the same race, physically, may have actually more differences than two people who do not look alike in terms of their race.
From a sociological perspective, we look at race as a social construction, not as something biological, because the differences by race that we see in how people are treated in society, their health outcomes, and their well-being as a whole are different. There's a different social experience and a different social context. A social construction is how we define race here. Identity could be at the individual, the group, or the universal level. Someone's personal identity, how they identify, and aspects of culture they identify with are part of their core identity. Multiculturalism refers to appreciating diversity, understanding group identities and cultural differences, and welcoming that.

Getting into the knowledge component of cultural competency, we have knowledge of cultural differences, differences in customs, differences in health philosophies, behaviors, health-improving behaviors, and norms. These all affect mental health. Everything that we're talking about in terms of disparities, these components of culture and cultural competency, all affect mental health, and are documented factors and drivers of mental health outcomes. Cultural factors in mental health outcomes could be related to things like barriers to mental health care. It could be about the role of the social context that we live in. Social context is the broader set of norms, values, and beliefs in broader society. It's how people are portrayed in the media, it's the political climate, it's the economic situation of a certain society  or smaller community. It’s everything that's going on outside the individual, the things that affect us collectively and affect people in different sectors of society with different social statuses differently.

The culture of mental healthcare, the bias, or the limitations of interventions is an interesting topic because it has to do with the fact that our diagnosis and our treatment in behavioral health and healthcare have a culture to them. They're not necessarily objective in the grand scheme of things. They are also culturally based, and they're often looked at as objective because they're driven by scientific discoveries and the like. They also have a culture to them. It's very significant.

Role of Culture in Mental Health

The role of culture in mental health: these are just a couple of the ways that culture affects mental health. First, it can influence how clients present symptoms and their subjective experience. We're keeping in mind that from one culture to another there can be a big difference in the interpretation of what's happening mentally. For example, with depression: if you're in an individualistic society, you may be interpreting that as personal misery and despair. In a more collective society, you may be internalizing things at the group level, and there's less of a focus on the individual. This can seem very different to us in the United States where we're zeroing in on that individual experience.

In terms of diagnoses of mental health conditions, they vary quite widely across cultures--things like attention deficit disorder. The set of behaviors that might be used to diagnose attention deficit disorder, for example, in another culture may be more tolerated and therefore not looked at as an abnormality. That is part of the difference in interpreting and diagnosing different mental health conditions.  Symptomology can be looked at as abnormal in one society, normal in another. Whether we define something as an abnormality or a disorder is culturally based, including our own system here in America where mental illnesses are classified according to Western systems and worldviews. That's just something to be aware of. It can help us have an openness to different cultural elements when it comes to the interpretation and presentation of symptoms related to mental health issues. Just being aware of that can help cultivate that open-mindedness--not to switch your views, but to be able to gather information-- culturally relevant information--from the client that may greatly affect the relationship between provider and client (Hinshaw et al., 2011; Maslowski et al., 1998).

Cultural Factors and Barriers to Behavioral Healthcare

Moving on to more cultural factors and barriers to behavioral healthcare. These are part of that set of factors that are culturally based that drive, or at least influence mental health outcomes. There could be physical barriers and a lack of providers based on a geographical area. We see this in rural communities, but it’s not just rural communities where there's a major lack of providers. There may be a lack of providers with the same background as a client. Oftentimes people who fall into minority populations might have a desire for this, so that the cultural issues are more understandable on the part of the provider.

Cultural mistrust of mental health interventions in general can have to do with historical injustices, cultural appropriateness of intervention, and consideration of the client's values and beliefs. For example, beliefs regarding their spirituality, beliefs associated with their religion, resource barriers, lack of insurance cost, language barriers, transportation barriers, and stigma in help-seeking in terms of mental health. Sometimes there's a stereotype that there's a stigma in certain cultures in terms of seeking services, but in actuality, it's an economic barrier, not a stigma.

Racism and Mental Health

Racism is an example of the social context and how that can affect mental health. We have an abundance of research on how racism, including discrimination, profiling, and microaggressions, are linked to more emotional distress, PTSD, depression, anxiety, self-esteem issues, and alcohol, and substance misuse. It affects social wellbeing. It can affect educational attainment. It can affect physical well-being. There's a whole scientific discipline called psychoneuroimmunology. This field studies how that social context, which affects your psychology, affects your physical body. We know that the experience of discrimination over time is cumulative in terms of its effect on both mental health and physical health. You have that release of cortisol that can help you in the short term and harm you when it's a long-term production of cortisol in the body. It can affect the degradation of your body in general, your risk of heart disease, and high blood pressure. It can affect body mass index and poor overall health. All of this gets into the body (Paradies, 2006).

Societal “Structural” Conditions

Looking at societal, or we refer to them as structural conditions, different from social factors and statuses. We're looking at these again in terms of their effect on mental health. Racial segregation, controlling for socioeconomic factors, controlling for the socioeconomic status. By the way, that is a measure that includes your income, your wealth, and your occupation; it can also include education. We can look at the socioeconomic status at the neighborhood level and at the city level. Controlling for that, when we have segregated communities, it can influence and contribute to mental health outcomes.

By the way, in the field of medical sociology, one of the assumptions is that health and illness are not randomly distributed across a geographical area or across groups. So, you can imagine a map of a community and almost like a Doppler radar when we see meteorologists present the weather systems. There are hotspots of certain illnesses, certain mental health conditions, physical health conditions. When we map onto that socioeconomic status, but also things like racial segregation, we see those hotspots of illness. That tells us that it's not necessarily random. There are social factors and structural conditions that are related to those outcomes, things like mass incarceration. We know that incarceration very disproportionately affects different groups, adverse childhood experiences, and this can lead to a higher likelihood of interacting with the criminal justice system. If a child has parents that are away, that are incarcerated, this can lead to adverse childhood experiences, which most of you probably know is related to mental health, but also related to physical health, and chronic illnesses in adulthood. Institutional racism and sexism, both historical and contemporary, affects mental health.

In general, the social experience based on socioeconomic factors, gender, sexuality, religion, disabilities, and other social statuses that we call social statuses. Much of the time fits into a social hierarchy, which means not necessarily at the individual level, but within a society, there’s a difference in the treatment, the social norms and ways of interacting with people that fall into different groups. Poverty, neighborhood deprivation, and unemployment affect mental health greatly. 
Displacement, loss of culture, and sense of belonging. If a culture is physically displaced, and there are examples that go way far back into history, hundreds of years ago where if a group is displaced, moved to another location, or the culture breaks down, there are higher rates of substance abuse, there are higher rates of overdose. It has a massive effect on the entire group as a whole. Social capital is like capital, only instead of monetary resources, which means more social resources, social cohesion, and the closeness of the group.

Redlining, reduced investment, blocking out people of certain groups accessing loans and resources in general, or employment. That includes services, schools, and hospitals. A neighborhood might have their property taxes, you know, their property values go down and then the schools suffer because that’s where they’re getting their funding. They could go out of business, and they don’t have a school. All of that has a massive effect on a neighborhood, a group, a culture, the built environment, and how a community is structured to foster social interaction and safety. All of those things affect mental health (Cummings et al., 2017).

Structural Racism

Structural racism; a defined by the Aspen Institute as "A system in which public policies, institutional practices, cultural representations, and other norms, work in various, often reinforcing ways to perpetuate racial group inequity, dimensions of our history and culture that have allowed privileges associated with 'whiteness' and disadvantages associated with 'color' to endure and adapt over time." (The Aspen Institute, 2016). Suppose you hear the concept of structural racism or systemic racism. In that case, it's that level above the individual where this is something that has gone on in history and continues today, where there are simply privileges and disadvantages by group.

Structural Competence

Structural competence is a great adjunct to cultural competency. Structural competence is the ability to discern how these downstream clinical symptoms, problems, and diseases are influenced by upstream social determinants of mental health. I'll break that down a little bit in terms of upstream and downstream. Downstream factors are things that may affect a health outcome quickly. They're the things that we're observing -  clinical symptoms, suicidal ideation, or something physical like a heart attack that leads to death. Things that happen downstream are those things that fall into emergency situations. 

Going a little further upstream we have health behaviors; further upstream, the social context, relationships, family situation, home environment. Even further upstream, we have the economic level, political level, and policy level. Problems that are happening at the systemic level are identified as problems in terms of their influence on these health disparities. Recognizing the history of pathologizing responses to trauma, there are truly disturbing aspects of history and how things are medicalized and were medicalized, and pathologized. Things like drapetomania, which was defined as the desire to escape slavery. These illnesses were legitimate diagnosable illnesses, essentially justified inhumane treatment and structural racism, and impacted diagnosis and mental health treatment. In other words, a trauma response to something external was then labeled as a mental illness. When we take that to today, if we're focusing only on that symptomology and we ignore those broader social factors, we could be missing a large part of the story (Metzl & Hansen, 2014; Willoughby, 2018).

Client Perspectives of Culturally Competent Psychotherapy

Looking at client perspectives of culturally competent psychotherapy, these are some important issues: understanding cultural issues, recognizing bias, using the social justice framework, having the desire that their therapists be advocates in terms of social problems, and preference of the same race therapist. As a side note: the outcomes may not always be better--you can rest assured if you are not the same race or of the same culture as your client, it doesn't necessarily mean you’re going to be less effective.

A study showed that a cross-cultural counseling inventory had a greater impact than only the counselor rating form on satisfaction with their provider among minority clients. This shows that there is some evidence of a positive impact of practicing cultural competency. This is also a sidebar, but a very important one (Constantine, 2002; Fuertes et al., 2006).

Knowing and Not-Knowing

When we talk about knowledge and gathering all the facts, there are things we may know, but practicing and embracing not knowing, and being open about what you don't know, can be powerful. It's like taking accountability. Oftentimes in our society, if we take accountability, if we show our biases, our lack of knowledge in certain areas, it can be associated with weakness, or you may not think that you're going to be respected.

That is a cultural thing, and breaking that down can be powerful at the individual level. Knowledge can include knowledge of cultural influences on care, the efficacy of care, culturally specific resources, programs and policies, and what’s out there that could help certain groups. If you avoid sensitive topics altogether, it can be detrimental. It can be beneficial and meaningful to have that dialogue. We don't have to know at all. When in doubt, you can ask a client to explain further, and you can always ask about how the social, or political environment may be affecting them personally.

Making the Connection

We're making the connection here: how does this form of knowledge fit into the other components of cultural competency? No matter how wide-ranging your knowledge base, awareness of these broader factors matters to clients, and individual-level care is impacted by understanding this broader context.

Attitudes and Cultural Humility

Knowledge can shape our attitudes. It can help us cultivate awareness, That's a great foundation for the skills you can pick up. Attitudes refer to things like embracing diversity, inquisitiveness, and having a positive attitude towards cultural differences. Practicing cultural humility, as distinct from cultural competency; viewing other mental health paradigms (which could be very different from the paradigm we ascribe to) as having value, emotional intelligence, and avoiding stereotypes. Cultural humility is different than cultural competency, and this is the definition that I gravitate towards in terms of how it could be impactful. It's a lifelong practice of self-evaluation, self-reflection, and self-critique. You're digging deep to understand where you're coming from and your biases. It's about reduced power imbalances. As I just talked about--vulnerability and taking accountability for potential biases and potential harm-- can be very influential in the therapeutic alliance. It also could include advocacy, community outreach, and organizational partnerships. We're looking at competency as more akin to knowledge, whereas cultural humility is more about not knowing (Tervalon & Murray-García, 1998).

Awareness

Having a bias isn't necessarily a bad thing. It's your own values, your own culture, and their impact. Ethnocentrism is looking at your own culture as the standard and looking at other cultures as other, as different. This shows up even in the “DSM-5”: there is an appendix of more culturally based disorders, that are set aside. In contrast, things like anorexia nervosa, for example, are also culture-bound, but is not included in the category of culture-bound illnesses. This is an illness that is more prevalent in Western cultures. Looking at differences in the impact of social issues, we’re simply being aware of institutional and intervention bias. We’re looking at approaches to behavioral health and being aware that they aren't culture-free, and there are cultural differences in engaging with care.

Skills

There are three skills outlined by Cardemil and Battle (2003). You can suspend preconceptions about the client and the family's race and ethnicity. You can recognize that clients may be different from other members of their same racial and ethnic group. You can consider how these differences between the therapists and client could affect psychotherapy. You can acknowledge that power, privilege, racism might also be affecting interaction with clients. Erring on the side of discussion again, you might be in doubt of what the significance is of culture. You can continue to receive ongoing professional development in culturally competent practices (Cardemil & Battle, 2003). This is from 20 years ago. It still applies today.

Anti-Racist Care

Working on the level of addressing some of those social factors, this addresses internalized racism, collective trauma, and emotional regulation. Black psychologist  Kenneth Hardy talks about the concept of the assaulted sense of self. This means that there's an internalization of the externalized racism that happens at the societal and cultural levels. Once that is internalized, it can affect self-esteem. How could this affect therapy? An example is looking at self-esteem issues. Working with that just as an individual thing, versus considering that this may be societally-based. Being aware of that and engaging in discussion with the client may have a positive impact there.

We consider care differences, like over-prescribing and mistrust. We can address those issues, taking the time to explain pharmacological treatment, the reasons, the side effects, and we gather information on a wide variety of cultural factors. We'll talk about that in terms of assessment as a culturally competent skill. The American Psychological Association (2020) has deemed racism a pandemic. This is coming late to the party, but nonetheless it is part of bringing awareness of some of these issues. Looking at it as a public health issue, as a mental health issue, as a pandemic that is spreading, that can be addressed. There's a treatment for this pandemic (Cénat, 2020; Ogundare, 2020; Singh, 2019).

Culturally Competent Assessment

Moving into culturally competent assessment, there is in the "DSM" something called the Cultural Formulation Interview. We can use that to gather information related to culture. We're not assuming homogeneity. This set of assessments, and there are lots of different assessments, can gather information on how symptoms may be related to things like racism and socioeconomic issues.

Culturally competent assessment recognizes the impact of these issues, such as mass incarceration and police violence, and how these can affect individuals. It assesses both the individual factors and the collective protective factors, strengths, and resources. Resources could be religious and spiritual, and culturally-based. It could be a culture where there's more social cohesion, or more collectivist, and these can be a strengths and protective factors. For all of the risk factors, there are also protective factors. We're going to look at two frameworks for culturally competent assessment.

• The RESPECTFUL Framework - An acronym of the different aspects of culture (D'Andrea  & Daniels, 2001):
  • R-religious/spiritual identity
  • E-economic class background
  • S- sexual identity
  • P-level of psychological maturity
  • E-ethnic/racial identity
  • C chronological/developmental challenges
  • T- threats to well-being and trauma
  • F-family background and history
  • U-unique physical characteristics
  • L- location of residence and language differences

This is information you may be already collecting; it can serve as a base for conversation and deepen your understanding of your client.

• The ADDRESSING Framework – is similar and also an acronym (Hays, 2001).
  • A- age/generation
  • D- disability status (developmental)
  • D- disability status (acquired)
  • R- religion/spiritual orientation
  • E- ethnicity
  • S- socioeconomic status 
  • S- sexual orientation
  • I- indigenous heritage 
  • N- national origin
  • G- gender

Other Scales and Tools

I mentioned the Cultural Formulation Interview and there is a Trauma Symptoms of Discrimination Scale. Deepening your understanding of discrimination and how that gets into the mind and body is fascinating. There's lots of research on how the social environment gets into the body and is passed on generationally. There's research that, for example, our grandmother's social environment affects our genetics. The field of epigenetic studies this. Consider two generations ago, and what was going on in society two generations ago. It’s pretty bad now, in terms of inequality, but go back two generations. There are other sets of issues that can have an effect on present day, the present generation (Cénat, 2020). Other tools: Everyday Discrimination Scale, UConn Racial/Ethnic Stress and Trauma Survey and, again, the Cultural Formulation Interview.

Communication

Communication applies to any client, but these are some tips when it comes to developing culturally competent skills in communication. You may already do this, but it's food for thought to take into your day-to-day. You can ask clients to describe their identity versus prescribing an identity (again, learning about a culture and then putting that on them or making those assumptions may not be exactly correct). You can ask about ideas, experiences, and beliefs. Consider that cultural and historical factors influence the etiology, symptom presentation, interpretation, how they talk about their mental health issues, and how that interacts with family pressures, cultural pressures, and stigma. The idea that therapy for a long time was associated with something that white individuals did. In your one-on-one communication, just knowing, and not assuming that there’s a universal in terms of symptom presentation and diagnosis. Note in-group differences to avoid inaccurate assessments or racial bias. Again, that's turning the cultural knowledge into a stereotype--avoiding that.

Resisting avoiding gathering information due to discomfort, and moving through discomfort. This applies to all of our relationships, right? When there's a conflict, when there's tension, when there's a power differential--being able to break that down and work through that can lead to a more meaningful connection. You can also consider more structured interviews versus unstructured ones. That relates to that discomfort. If there's a lot of discomfort, needing to know how to start the conversation, how to keep that conversation going, or what to take from it, you can use more structured interviews to gather that information as a starting point.

Beyond the Individual: Community-Based Interventions

As was mentioned before, cultural competency is a continuum, but it's also a continuum from individual all the way up to the policy level. You can integrate community-based interventions. This might be something that you do, and it might be something at the agency level. Many coalitions in communities have certain goals to address health and social issues in that community. I lived in a small town for many years, and there were many coalitions of people that came from different cultural backgrounds and political ideologies, and there were common goals. For example, ending child abuse or raising the high school graduation rate in the county. Understandably, you have, probably, a heavy workload and a lot going on. Being able to go outside of that, if you do have the time to join those coalitions, you can bring your expertise in the mental health field to interventions, whether that's disseminating mental health information or partnering with those community organizations or coalitions to bring that expertise. You can bring ideas to the table, assist individuals with resources and access, and even provide services. What we're talking about here is meeting people where they're at. If there's a barrier to care, doing something like a pop-up where you're providing some care, or maybe some assessments, similar to pop-up medical care, like a pop-up diabetes clinic or providing oral healthcare.

Policy Recommendations: Education and Research

Now we get into policy recommendations. We have covered the societal view and different societal issues, social factors, systemic issues that affect mental health. How structural issues have a trickle-down effect on clients. How those issues can be embedded, not only in their mind but in their body, and can affect how they are engaging with their mental health.

After looking at that big picture and how that affects individual care, now we’re moving back up to that policy level, which is something that many folks in the mental health fields have called for in terms of engaging more at that policy level as a mental health professional. At the educational level and the workforce level: recruiting, mentoring, and striving for a more diverse workforce. It does matter to have professionals at the table with that lived experience, and have more options for clients to have a provider who is of the same race, or cultural background that, again, may be more understanding of those issues. That’s not to say that there can be an assumption there when two people are of a similar culture. The same skills apply to collecting that information specific to that individual. 

The educational level: inclusion of cultural competency education and looking at different forms of education. I've tried to find evidence of when training works, because the truth is that the disparities we see persist. They're not going away. There is a question, and there is a debate: is cultural competency training making an impact? That's why, personally and professionally, I'm passionate about looking at that big picture, and including cultural humility. The educational practice that is a best practice is experiential learning. Spending time in a certain community with a different culture than you and becoming kind of embedded. Communicating, but mostly listening to people in that group that is different from your background, is very influential in that attitude and awareness piece.

We want to dedicate time and resources for any mandated training. If you're having to go to a training (and you're going to a training right now), having that time, and having resources. If it's happening at the organizational level, it’s putting time and resources behind that. Advocacy for interpreter services, incentivizing buy-in at the leadership and administrative levels, and expanded funding from government agencies and hospital systems to improve cultural competency (McGregor et al., 2019).

At the research level: this is critical as there is an unbelievable dearth and lack of research on the efficacy of therapies on a variety of different cultures and races. Research is needed on these underlying factors that explain these disparities, not just at the individual level. Program evaluation of cultural competency training: as I said, finding where the best practices are. More research on the client experience and more assessment of these other components like humility and empathy, and I would add vulnerability and accountability. Assessing when those skills and qualities are present, what's the effect on the health outcome? More diagnostic research, looking at the reliability and validity of different assessments, increasing studies on diverse populations, more diversity among researchers, and interdisciplinary approaches. As mentioned, those other fields such psychoneuroimmunology added to the research base (Ogedegbe, 2020; Singh, 2019).

Summary

There's a difference between cultural competency and competency, right? Cultural competency is a set of qualities. It's a lifelong practice that includes inner work for us to do. Based on what we know, the quality of the interaction is more important than anything. That's what we want to influence. We can't assume that knowledge of cultural differences automatically translates into more effective interventions (Shim, 2020).

Our general knowledge is very good for understanding that there are cultural differences and systemic inequalities. That's our base, and then we grow into being more comfortable discussing these issues and working on that humility piece. The empathetic inquiry is preferable over extrapolation, or taking your knowledge base and making those assumptions. Finally, a holistic approach to cultural competency also can include outreach, advocacy, and even engagement with policy change. 

Thank you. Your time is appreciated.

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