GENDER AFFIRMING ART THERAPY 1 Art Therapy with Transgender and Gender Diverse Youth: Gender Affirming Considerations Kaitlyn Rice ARTT 791 ADV AT Research Department of Art Therapy, Edinboro University Dr. Orr GENDER AFFIRMING ART THERAPY 2 Abstract This paper examines art therapy with gender diverse and transgender youth in the United States. The issue addressed is the current, inadequate, and inapt ethical guidelines posed by the American Art Therapy Association for art therapists working with gender diverse and transgender youth. Additionally, there is a lack of literature and research about the effectiveness of art therapy with transgender and gender diverse youth, as well as art therapist and therapy considerations. To address this problem, the purpose of this paper will be exploring the community’s history of pathology and stigmatization, as well as gender affirming approaches to art therapy when working with transgender and gender diverse youth. Proceeding this paper is an 8-week art therapy group addressing the complex and unique mental health needs of this community. This paper can provide literature and considerations in art therapy practice to effectively work with gender diverse and transgender youth. Keywords: transgender, gender diverse, art therapy, gender affirming care, stress minority theory, WPATH, SOC GENDER AFFIRMING ART THERAPY 3 Definition of Terms A note to the reader: These terms are everchanging and can mean different things to each unique individual. As a mental health professional, it is important to ask the client about their preferences and what these terms mean to them. Gender Affirming Care- Services with a philosophy focusing on affirming an individual’s gender expression and identity, providing support and recognition of said gender identity and expression which may include reversible and/or irreversible intervention. Gender Diverse- A term utilized to describe persons whose gender identity is diverse from the gender binary system; gender non-conforming can also be used and is utilized in this paper. Transgender- A term used to describe a person whose sex assigned at birth does not align with their gender identity; transgender individuals may wish to transition to align their gender identity and expression, however, an individual does not need to transition in order to be considered to be transgender. Sex Assigned at Birth- This is the label chosen for persons at birth based on appearance of genitalia at birth. LGBTQIA+- Lesbian, Gay, Bisexual, Transgender, Queer and/or Questioning, Intersex, Asexual and/or Ally Lesbian- A woman who is primarily attracted to other women. Gay- A term used typically to describe someone attracted to another person of the same sex or gender; historically, this term was used to describe men who were attracted to predominantly men. Bisexual-A person who’s sexual or romantic attraction is not exclusive to one particular gender GENDER AFFIRMING ART THERAPY 4 Queer-A term utilized to describe a nonconforming sexual identity; historically this term has been used as a slur but has since been reclaimed. Questioning-A term used to describe a person who is questioning or exploring their sexual and/or gender identity Intersex-A term used to describe a person who is born with variations in sex characteristics, such as gonads, chromosomes, genitals, or sex hormones that cannot be classified as female or male. Binary- In the context of the binary gender system, this term refers to the socially constructed system of two genders. Homosexuality- A term describe an individual who is sexually and romantically attracted to a person of the same gender; this term is no longer used in the context of medical and mental health fields but has historical context within this paper. Transphobia- Prejudice or strong dislike of transgender persons. Gender Transitioning- A term utilized to describe a person’s journey of transitioning to their preferred gender; this can include social transitioning, such as coming out, using preferred name, pronouns, clothing and hairstyles; this can also include medical interventions such as hormones and sex reassignment surgery. Gender Identity- The intimate, personal conception and experience of one’s gender role; each person’s gender identity is unique. Gender Expression- The way in which an individual expresses themselves, including physical appearance such as clothing and hairstyles, as well as behavior. Sexual Orientation- A person’s physical, emotional, spiritual, and romantic attraction of another person; every person has a sexual orientation. GENDER AFFIRMING ART THERAPY 5 Cisgender-A term used to describe a person whose sex assigned at birth matches their gender identity Nonbinary-A term used to describe a gender identity that is neither male nor female, also known as genderqueer GENDER AFFIRMING ART THERAPY Table of Contents Introduction ........................................................................................................................7 Literature Review ..............................................................................................................9 History of Gender Diverse and Transgender Rights ................................................9 1960s and Stonewall Rights .........................................................................9 1970s and AIDS Pandemic ........................................................................11 1990s, 2000s, & Obama Presidency ..........................................................11 Transgender Rights and Breaking the Binary ............................................12 Mental Health Concerns ........................................................................................14 Minority Stress Theory ..............................................................................14 Depression and Suicide ..............................................................................16 Gender Dysphoria ......................................................................................17 History of Medical and Mental Health Care ..........................................................18 Conversion Therapy ...................................................................................18 Transsexual Phenomenon ..........................................................................19 Gender Clinics ...........................................................................................21 DSM ...........................................................................................................22 WHO ..........................................................................................................24 Affirming Care and Considerations .......................................................................26 WPATH SOC.............................................................................................26 Role of Counseling for the Family.................................................28 Multidisciplinary Team ..................................................................29 Art Therapy Literature with Gender Diverse and Transgender Youth ..................30 AATA ........................................................................................................31 Additional Literature ..................................................................................33 Methodology .....................................................................................................................39 Target Audience .....................................................................................................39 Curricular Structure ...............................................................................................40 Group Facilitator Considerations for Affirming Therapy ..........................40 Art Therapy ................................................................................................40 Theoretical Supports ..................................................................................41 Curricular Structure ...............................................................................................43 Curricular Guide .............................................................................................................44 Discussion..........................................................................................................................67 References .........................................................................................................................70 Appendices ........................................................................................................................77 6 GENDER AFFIRMING ART THERAPY 7 Art Therapy with Transgender and Gender Diverse Youth: Gender Affirming Considerations Section I: Introduction The gender diverse community, their civil rights, and challenges have shifted to center stage within the last century. Conversely, this population has been fighting to be heard through the noise of discrimination, oppression, and prejudice, especially when accessing affirming mental health care. Mental health practitioners have been playing a “very complex and controversial role” in treatment of gender and sexual minorities (Lev, 2018, p. v), from pathologizing gender and sexuality, to gate-keeping affirming interventions. The field of art therapy is despondently lagging behind. The American Art Therapy Association (AATA) released a statement in 2017 stating the organization “embraces and affirms individuals within the LGBTQI spectrums of sexual orientation and gender-diverse and transgender individuals” as well as supporting “therapeutic interventions that foster healthy development” (American Art Therapy Association [AATA], 2017). The incongruent and blanketed use of affirming and sexual orientation demonstrates the lack of competency about this community. Art therapy research with gender diverse and transgender youth is more than sparse. This is problematic because exploration of gender expression is a significant component to genderaffirming treatment with unique novelties that an inexperienced art therapist may miss completely, or worse, cause harm. Gender diverse and transgender youth contain “a range of transition-related needs” (Austin, 2017, p. 73), requiring “support of informed practitioners with transgender and gender diverse-specific knowledge and skills.” Therefore, art therapists are “ethically obligated to act as affirming safe adults and advocates” (WPATH, 2011, as cited in GENDER AFFIRMING ART THERAPY 8 Stark & Crofts, 2019, p. 19), demonstrating the need for standards, gender affirming treatment, and research in the field of art therapy with gender diverse youth. Only a relative cluster of art therapists have noted their research and approaches with the gender diverse community. These studies have briefly scratched the surface of populationspecific experiences such as erasure of gender diverse community in art therapy, affirmative therapy, sexual orientation, and the lack of standards when working with this field. There is currently only one published book about art therapy with transgender and gender diverse youth, Art Therapy with Transgender and Gender-Diverse Children and Teenagers, by Darke & ScottMiller. Shockingly, and this book was published in January of 2021. The scarcity of information and treatment standards in art therapy practice, withholds responsibility of the field to practice effectively and ethically through an affirming approach. Art therapists and the field of art therapy need to actively move “beyond the binary of male and female” (Darke & Scott-Miller, 2021, p. 10) in order to support “an individual’s unique gender identity and expression.” Conclusion Due to the alarming rate of mental health issues experienced by transgender and gender diverse youth, it is essential to identify specific considerations in order to achieve and maintain competency to effectively meet the needs of this population. Mental health professionals play an essential role in supporting gender diverse and transgender youth. Consequently, the purpose of this project is to develop a gender-affirming curriculum for art therapists to utilize when working with gender diverse and transgender youth in a group setting, aligning with the World Professional Association for Transgender Health’s (WPATH, 2012) Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People (SOC). GENDER AFFIRMING ART THERAPY 9 Section II: Literature Review History of Gender Diverse and Transgender Rights It has been decades of uphill battles for LGBTQ civil rights in The United States, which are still being challenged in the 21st century. Most of the individuals in the forefront of this movement were gender diverse and transgender but their legacy has been “stamped indelibly onto the rainbow pride flag” (Brown, 2019). Including transgender in the LGBTQ acronym further confuses the conceptualization and differentiation between gender and sexual identity. Transgender is a gender role, nor a sexual orientation. It should be noted that much of history and research has grouped transgender individuals with individuals who sexually identify as lesbian, gay, bisexual, and queer. Nevertheless, in order to conceptualize the mental health needs of this community, understanding the enduring history of civil rights is vital. The early gay rights movement began around 1924, when Henry Gerber established the Society for Human Rights, the U.S.’s first documented gay rights organization (History, 2017), only to be disbanded a year later due to police raids. The movement became somewhat stagnant for a decade or two, but quickly picked up the pace in the 1950s when Harry Hay founded the Mattachine Foundation (CNN, 2021). Mattachine Foundation was the first gay rights group in the U.S. and coined homophile, a term which was “considered less clinical and focused on sexual activity than homosexual” (History, 2017). Hence, this decade was labeled the homophile years, with subsequent LGBTQ groups emerging. Transitioning into the 1960s, the LGBTQ movement shifted to the political front stage. 1960s and Stonewall Riots LGBTQ individuals were living in “a kind of urban subculture” (History, 2017) where they were “routinely subjected to harassment and persecution” within the community. GENDER AFFIRMING ART THERAPY 10 Consequently, a “sip-in” was staged, modeled after the “sit in” racial civil rights protests of the 1960s (History, 2017). Gay men and women declared their sexual identity while visiting taverns, hoping to be denied service in order to sue to overturn discriminatory liquor laws. These laws were quickly overturned, which was one more step towards the catalyst of the gay rights movement in the U.S. In 1969, the Stonewall Riots erupted. The Stonewall Inn, the LGBTQ heart of Greenwich Village, was deemed a ‘gay club,’ and most of the patrons were gay men of color or drag queens. On June 28, 1969, New York City police raided the Stonewall Inn during the early hours of the morning. As arrests were being made, neighborhood residents and patrons started throwing objects at police, fueled by the decades of police harassment (History, 2017). This eventually erupted into a “full-blown riot, with subsequent protests that lasted for five more days” (History, 2017). Marsha P. Johnson was one of the front-line demonstrators during these riots, a Black transgender female. Her advocacy and visibility were crucial during the initiation of the gay rights movement. Individuals like Johnson “lived at the intersection between racism and homophobia” and adopted the role of “political agitators that helped advance the mindset of society” (Brown, 2019). Following the Stonewall riots, many more LGBTQ groups were created, including Johnson and Sylvia Rivera’s transgender youth organization, STAR (Street Transvestite Action Revolutionaries). At the first anniversary of the event, community members of NYC covered the streets to commemorate the event, established as the Christopher Street Liberation Day, the country’s first Gay Pride Parade. Much of history notes the Stonewall Riots as a gay movement, continuing the erasure of the vital role trans individuals played. GENDER AFFIRMING ART THERAPY 11 1970s and AIDS Pandemic During the 1970s, LGBTQ activities helped advance and “secure some municipal and state-level protections against discrimination in public employment” (Fitzsimons, 2018), with many individuals appointed into office as well as increased visibility. In 1977, Renée Richards, a transgender female, was provided the opportunity to play at the United States Open tennis tournament in the women’s league. Harvey Milk, the first Californian openly gay man to be elected to political office and Gilbert Baker, a gay rights activist and artist, created the infamous rainbow flag, which was revealed during the 1978 pride parade. Unfortunately, LGBTQ civil rights, specifically gay rights, moved to center stage during the outbreak of AIDS in the United States during the 1980s and early 1990s. In 1981, reports of an atypical lung infection infiltrated the news, specifically identifying the individuals as gay men. Consequently, “anti-gay reaction gained steam” (Fitzsimons, 2018) throughout America, coining the term “the gay plague.” It was not until 1983, that AIDS began developing through heterosexual sex. During the 90s, federal policies, laws, and bills began to pop up intermittently. Clinton’s “Don’t Ask, Don’t Tell” military policy was signed in 1993, prohibiting openly LGBT individuals from serving, forcing service members into secrecy (CNN, 2021). The policy also prohibited discrimination and harassment against LGBT service members. However, if the policy was violated, or service members “were found to have engaged in a ‘homosexual conduct’” service members would face possible discharge. This policy was not revoked for another 18 years. 1990s, 2000s, & Obama Presidency Marriage shifted to the mainstage of LGBTQ rights during the late 1990s into the early 2000s. In 1996, Hawaii would be the first state to acknowledge lesbian and gay couples have the GENDER AFFIRMING ART THERAPY 12 right to marry and are eligible for heterosexual marriage rights. This sparked a response from Congress within the same year, which resulted in the Defense of Marriage Act (DOMA). DOMA, signed under Clinton, defined marriage as “a legal union between one man and one woman as husband and wife” and a spouse as “a person of the opposite sex who is a husband or wife.” Therefore, this law permitted states to deny rights to same-sex couples such as insurance benefits, Social Security survivor’s benefits, tax filing, and immigration (Perlata, 2013) as well as recognition of same-sex marriage certificates from other states. In 1998, the murder of Mathew Shepherd shocks the world and LGBT community, ultimately impacting several laws and rulings in the early 2000s. The US Supreme Court revoked Texas’s anti-sodomy law in 2003, which “effectively decriminalized homosexual relations nationwide” (History, 2017). In 2009, President Obama signed the Mathew Shepherd Act that expanded the 1994 hate crime law. This law would make it a federal crime to assault an individual due to their gender identity or sexual identity. The law would be known as the “first major federal gay rights legislation” (CNN, 2009). Following this forward momentum, “Don’t Ask, Don’t Tell” was repealed in 2011 and 6 states are granted same-sex marriage rights in 2014. The period between the second term of Obama’s presidency and the 2016 election exhibited continuous forward motion for the LGBTQ community. In 2015, the US Supreme Court finally rules same-sex marriage as legal, a hug win for the LGBTQ community. LGBTQ individuals were appointed more positions in office, competing openly “out” in the Olympics, protection in the workplace against discrimination, and the military lifted the ban of openly transgender people serving. GENDER AFFIRMING ART THERAPY 13 Transgender Rights and Breaking the Binary Transgender rights have moved into the forefront of LGBTQ civil rights movement within the last couple of years, especially due to the political climate the Trump Administration brought upon the community. The Trump Administration modeled outward anti-trans and LGBTQ through rhetoric and policy. For example, in 2018, the Trump Administration enacted a policy that banned most transgender individuals from serving in the military. Nevertheless, LGBTQ allies continued to fight for civil rights in states such as non-binary restrooms, legal defense strategies that unethically utilized defendant’s sexual orientation or gender identity against them in court, and specific work discrimination laws protecting LGBTQ workers (CNN, 2021). In 2017, Boy Scouts of America began to allow transgender boys to join. Joe Biden’s presidential win brought about a slew of both positive and negative events for the LGBTQ population, specifically the transgender community. For example, Biden repealed the ban of transgender individuals joining the army. The Equality Act, presented by Democratic U.S. lawmakers in May of 2021, is awaiting Senate vote, which would “provide the most comprehensive LGBTQ civil rights protections in U.S. history,” (Schmidt, 2021) substantially “altering the legal landscape” of a country where most states do not explicitly protect citizens sexual and gender identity rights. Biden’s most profound move was appointing Dr. Rachel Levine, a transgender female, as the assistant secretary of health. The confirmation brought about a chain of reactions, manifested in the creation of transphobic lawmakers. Currently, a sweeping number of lawmakers have proposed anti-transgender bills, in at least 14 different states (Andrew, 2021). These bills criminalize gender affirming care to transgender youth, medical professionals that provide said care, and possible criminal charges for parents. In addition, anti-transgender bills under consideration include banning transgender youth GENDER AFFIRMING ART THERAPY 14 and adults from participating in sports, religious services, and updating legal documentation to preferred name and pronouns. It is essential as clinicians of the mental health profession to understand and acknowledge the ways in which this history of LGBTQ rights has destructively impacted the population’s mental health and well-being, including the erasure of gender diverse and transgender individuals from research as well as history. Mental Health Concerns It is important to understand that “gender identity and gender expression do not cause mental health issues,” (Brill, 2016, p. 203), but it is the “impact of negative reactions to a person’s gender, the harassment, discrimination, and social stigma” which creates the context for mental health issues for gender diverse and transgender youth. For those that remain closeted, psychological challenges that “come from suppressing core parts of one’s identity” (Lev, 2018, p. ix) are manifested “in mental health and behavioral struggles.” Consequently, transgender and gender diverse youth are at risk for stigma, discrimination, gender dysphoria, anxiety, depression, suicide, internalized transphobia, poor self-esteem, as well as drug and alcohol dependency (Pelton-Sweet & Sherry, 2008, p. 170). Therefore, transgender and gender diverse youth with “gender-related concerns do have significantly increased co-occurring psychopathology than the general population” (Leibowitz, 2018, p. 8). These concerns have a “cumulative effect on overall health” (Pelton-Sweet & Sherry, 2008, p. 171). Minority Stress Theory Minority stress theory is described as “a relationship between minority and dominant values and resultant conflict with the social environment experienced by minority group members” (Denato, 2012). The underlying characteristics stressors experienced by minority groups are unique, chronic, and socially based (Denato, 2012). In addition, stressors are GENDER AFFIRMING ART THERAPY 15 compounded, and severity depends on the number of “stigmatized social categories” (Meyers, 2003) the individual belongs to, including sexuality, gender, socioeconomic status, and race/ethnicity. For example, a Black trans female will experience stressors identifying with the transgender community, including access to care, in addition to stressors associated with being Black, such as racism. Therefore, a “strong correlation may be drawn between minority stress theory, which underscores experiences of “prejudice, expectations of rejection, and internalized homophobia” and a “greater likelihood for psychological distress and physical health problems” amongst sexual minority populations (Meyer, 2013). Stressors unique to the gender diverse and transgender youth population include victimization, discrimination, maltreatment, disclosure concerns to healthcare providers, and harassment, in addition to community and family gender-based rejection, ultimately significantly impacting daily living and functioning. The rate of violence and violent acts committed against the LGBTQ population, specifically the transgender individuals, has skyrocketed in the community and systems of power. According to Sage (2020), “1 in 3 LGBTQ youths reported that they had been physically threatened or harmed in their lifetime because of their LGBTQ identity.” Gender diverse and transgender youth experience non-affirmation, as well as “negative expectations for future events” manifested in the expectation of victimization and rejection from other people, in which an individual “navigates their world trying to avoid any potentially upsetting or dangerous situations” (Brill & Kenney, 2016, p. 194). As a result, gender diverse and transgender individuals experience internalized transphobia or homophobia internalizing continuous negative messages they hear about their gender, feeling “hatred, anger, or shame for who they are” (Brill & Kenney, 2016, p. 194). Consequently, gender diverse and transgender youth are more likely to “avoid care, even when it could be beneficial” (Leibowitz, 2018, p. 9), GENDER AFFIRMING ART THERAPY 16 or may not disclose trauma or negative events due to concerns of comfortability or safety. Further exacerbating medical and mental health care is the general deficit gap in training and education of the behavioral health and general medicine regarding transgender and genderdiverse population, in addition to policies banning affirming care. Hence, there is direct relationship between gender minority stress and mental health issues, such as suicide. Depression and Suicide The current and historical negative cultural and socioeconomical conditions in America continue to impact mental health conditions of gender diverse and transgender community. Many individuals face denial of civil and human rights, discrimination, prejudice, and harassment which can result in “new or worsened symptoms” (NAIMI, n.d.). LGBTQ youth are more likely to struggle with mental health compared to non-LGBTQ youth due to exclusive experiences of discrimination and stigma. Additional, unique risk factors of transgender and gender diverse youth are the coming out process, social transition process, inadequate health care, transphobia, and family rejection. These compounding factors can lead to mental health challenges. Compared to LGBQ and cisgender youth, transgender and gender diverse youth are “twice as likely to experience depressive symptoms, seriously consider suicide, and attempt suicide” (NAIMI, n.d.). According to Reisner (2015), one in five transgender youths have made a suicide attempt. Psychosocial factors, such as restroom access and social transitioning, have a “profound effect on transgender youth well-being” (Human Rights, n.d.). Selman (2016) reported transgender youth are 45% more likely to attempt suicide due to college campuses denying access to gender affirming facilities. Social transitioning can bring about feelings of anxiety, specifically withdrawal and avoidance, due to fear of being singled out as part of the transition process. Gender diverse and transgender youth may also experience symptoms of GENDER AFFIRMING ART THERAPY 17 anxiety and depression through internalized binary gender roles. Some gender diverse and transgender youth may experience a more severe form of anxious and depressive symptoms related to dysphoria. Gender Dysphoria Transgender and gender-nonconforming youth may experience gender dysphoria, a feeling of clinically significant distress and discomfort related to the incongruence between one’s sex assigned at birth and their gender identity. DSM-5 criteria of Gender Dysphoria include: A strong desire to be rid of one’s primary and/or secondary sex characteristics because of marked incongruence with one’s experience/expressed gender (or in young adolescents, a desire to prevent the development of the anticipated secondary sex characteristics), a strong desire for the primary and/or secondary sex characteristics of the other gender, a strong desire to be of the other gender (or some alternative gender different from one’s assigned gender), a strong desire to be treated as the other gender (or some alternative gender different from one’s assigned gender), a strong conviction that one has the typical feelings and reactions of the other gender (or some alternative gender different from one’s assigned gender) (American Psychiatric Association, 2015, p. 452). Gender dysphoria is frequently accompanied with co-occurring complaints, “with approximately 20-30% of individuals presenting to a gender clinic meeting DSM criteria for an anxiety disorder” (Leibowitz, 2019, p. 8). Disruptive disorders, ADHD, mood disorders, and autism spectrum disorders are the next commonly co-occurring disorders. For individuals who do not receive gender affirming care, disordered eating may occur in order to “halt the progress of puberty and the physical changes of the body” (Leibowitz, 2018, p. 18). These dysphoric GENDER AFFIRMING ART THERAPY 18 symptoms are associated with clinical impairment in important areas of functioning in addition to aforementioned stressors of the transgender and gender diverse community. The sobering rate of mental health challenges of the gender diverse and transgender community inform the mental health field of the needs for this population. The research and identified gap in knowledge demonstrates the importance for clinicians to be trained and knowledgeable of these issues in order to provide gender-affirming care to LGBTQ youth. History of Medical and Mental Health Care The history of mental health care for gender diverse youth, specifically transgender youth, is rooted in prejudice and discrimination. Often times, non-binary gender expression and identity were pathologized by medical and mental health professionals. This mindset has lingered into the 21st century, exhibited in a “deficit gap in their education and training regarding working with gender diverse and transgender patients” (Lev, 2018, p. v). Lev states her book, Transgender Emergence: Therapeutic Guidelines for Working with Gender Variant People and their Families, was the first clinical book to “suggest that transgender identity was not a mental illness” (Lev, 2018, p. v), written just 15 years ago. The role of the helping profession has played a detrimental role in the conceptualization of mental and medical health of LGBTQ+ youth. Conversion Therapy Conversion, or aversion therapy, is a series of practices with the intention to “alter an individual’s sexual orientation, gender identity, or gender expression” (Graham, 2019, p. 419). This practice is unfortunately still being utilized in most states, with only 9 states banning clinicians from providing said service to minors. Conversion therapy believes the “lived expression of LGBTQ+ identity is normatively problematic and subject to correction” (Graham, 2019, p. 419). Its origin can be traced back to the 19th century, spreading from Europe to GENDER AFFIRMING ART THERAPY 19 America. Interventions were rooted in systematic prejudice and stigmatization, with the goal of ‘curing’ an individual. Such procedures included “castration, testicle implants, bladder washing, and rectal massage” (Graham, 2019, p. 419). In 1913, medical professionals began to move away from these techniques, realizing they did not necessarily work as resolving sexual orientation. During the rise of psychotherapy, some mental health professionals adopted the conceptualization of the medical field and administered conversion therapy techniques through a behavioral lens. Nonetheless, physical interventions continued throughout the mid 20th century. Recommended and implemented techniques by psychoanalysts and psychiatrists included electroshock therapy and lobotomies in conjunction with talk therapy. During the 1960s, behavioral therapy implemented aversion techniques such as “inducing nausea or paralysis in response to homoerotic imagery and instruction patients to snap their wrists with a rubber band any time they were arouse” (Graham, 2019, p. 419). Additional non-physical techniques included improving assertiveness in men (believing weak mean and dominant women gave birth to gay sons), improving dating skills, orgasmic reconditioning, teaching stereotypical feminine and masculine behaviors, as well as hypnosis (Graham, 2019, p. 422). As the American Psychiatric Association (APA) began developing the Diagnostic and Statistical Manual of Mental Disorders (DSM), the ethics and effectiveness of conversion therapy came into question. Consequently, the “gilded age” (Graham, 2019, p. 422) came to an end in the late 1960s and medical and mental health professionals, as well as organizations, issued ‘statements which rejected conversion therapy on the grounds that it harmed the patients and largely did not produce desired results” (Graham, 2019, p. 423) over the next few decades. Transsexual Phenomenon GENDER AFFIRMING ART THERAPY 20 With transgender health care receiving attention in the media due to legislation and political climate, “providers can be misled to believe that trans medicine is a new endeavor in the United States” (Chang et al., 2018, p. 45). The history of transgender health care in America has a problematic and complex history. The first instance of pathologizing transgender people traces back to 1949, when David Cauldwell, an American sexologist wrote about “psychopathia transexualis” (Cauldwell, 1949). Cauldwell utilized eugenics language to coin transgender identity as a “condition” and a “deviation from an otherwise normal society” (Chang et al., 2018, p. 45) in which individuals come from a “poor hereditary background” with a “highly unfavorable childhood environment” (Cauldwell, 1949). Therefore, environmental influences and genetics became weaponized when conceptualizing non-conforming individuals. Transgender identity understanding shifted in 1966. A physician, Harry Benjamin, published The Transsexual Phenomenon: A Scientific Report on Transsexualism and Sex Conversation in the Human Male and Female, differentiating sex and gender as separate concepts, as well as sexual orientation and gender identity (Benjamin, 1996). Benjamin is also attributed as the first physician in America to treat transgender individuals. Chang et al. (2018, p. 46) describe Benjamin’s ideas as “a singular medicalized narrative” in which he was determined to classify “the true transsexual,” developing a rating scale to measure sexual orientation, gender variance, and one’s desire to change the body, with additional subcategories, including genital surgery and sexual attraction (Benjamin, 1996). However, these radicalized ideals pigeonholed transgender identity conceptualization and health care. Benjamin upheld and somewhat caponized binary gender norms by proposing that the “true transsexual” must “report something akin to being a man trapped in a woman’s body or a woman trapped in a man’s body” (Chang et al., 2018, p. 46). In order to access hormone therapy GENDER AFFIRMING ART THERAPY 21 or genital reconstructive surgeries, transgender individuals essentially needed to adopt this narrative to medical professionals” (Chang et al., 2018, p. 46). These “rules” and singular medicalized narrative have evolved into eligibility criteria, governing medical decision making in the 21st century. Gender Clinics In 1966, Johns Hopkins Gender Identity Clinic was established, specifically to provide sexual reassignment surgeries. Over the course of the late 1960s and early 70s, over 40 additional university-based clinics opened (Chang et al., 2018, p. 47). These clinics adopted Benjamin’s principles for medical transitioning, specifically providing services to White, transgender females. Additional exclusion criteria included individuals who did not disclose ‘cross-dressing’ in childhood and individuals who had children or heterosexual relationships. In 1979 the clinic released study findings stating treatment was ineffective due to patient expressing symptoms post-surgery concluding that “transgender patients who underwent reassignment surgery were not better than those who went without surgery” (Khan, 2016). This ultimately led to the clinic’s closure, despite methodological flaws. Over the next ten years, all remaining gender clinics closed due to the movement of standardization and privatization of transgender health care. The aforementioned Harry Benjamin founded the Harry Benjamin International Gender Dysphoria Association (HBIGDA) in 1979, as a response to Johns Hopkins Gender Identity Clinic’s accusations in “an attempt to standardize care” (Khan, 2016). These standards provided treatment guidelines for medical and mental health professionals for transgender individuals seeking gender-affirming care and created an echo of controversy. Some clinicians and transgender individuals argued that medical professionals became gatekeepers of treatment in GENDER AFFIRMING ART THERAPY 22 which transgender individuals were determined as ‘ready’ or ‘unfit’ for medical transitioning by said guidelines, maintaining “control over trans people’s transition trajectories” (Chang et al., 2018, p. 49). Without expressing the universal narrative, transgender individuals were typically denied care. Moreover, the privatization of transgender health care further exacerbated healthcare disparities within the community, making treatment costs astronomical for patients, of which most paid out of pocket. Furthermore, Medicare excluded gender-affirming surgeries from coverage in 1989, and for over 25 years. A note to the reader, the HBIGDA transformed into The World Professional Association for Transgender Health (WPATH), renovating said narrative and vision. Today, WPATH’s SOC is the world’s leading document to assist medical and mental health professionals with providing ethical, evidence-based healthcare to transgender and gender non-conforming individuals. DSM Psychiatric and health organizations have played a role in the stigmatization of sexual orientation, gender expression, and gender identity. In 1952, APA published the first edition of the DSM), branding ‘homosexuality’ as a psychiatric disorder. ‘Homosexuality’ was classified as a personality disorder, under subcategories of sexual deviation and sociopathic personality disturbance clustered with “transvestism, pedophilia, fetishism, and sexual sadism (including rape, sexual assault, mutilation)” (APA, 1952, p. 39). In the second edition of the DSM, published in 1968, ‘homosexuality’ was no longer considered to be a ‘sociopathic,’ (APA, 1968, p. 41), but continued to be classified as ‘sexual deviation,’ ‘paraphilias,’ and a non-psychotic mental disorder.’ Soon after the second edition was published, civil rights activities and the public forcefully challenged APA’s conceptualization of ‘homosexuality.’ GENDER AFFIRMING ART THERAPY 23 The de-stigmatization of sexual orientation would see a trend over the course of the DSM’s publications, with civil rights activists of the LGBTQ+ community initiating said change. In 1970, gay rights activists disrupted APA’s annual meeting with a demand for change, specifically calling for the removal ‘homosexuality’ from the DSM. Consequently, “APA embarked upon an internal deliberative process, “in which the organization would continuously grapple with the question, “Should homosexuality be in the APA nomenclature?” (Drescher, 2015, p. 387). After three long years of deliberation and unbroken activist momentum, APA definitively removed ‘homosexuality’ from the DSM, concluding that ‘sexual deviations’ “regularly caused subjective distress or were associated with generalized impairment in social effectiveness of functioning” (Drescher, 2015, p. 388) and that “homosexuality per se” was not a mental disorder. However, it is essential to note that this decision caused an uproar, specifically with psychoanalysts of the field, conducting their own vote and study, which ultimately, did not prevail. Nonetheless, “psychiatry’s pathologizing of homosexuality still persisted” (Drescher, 2015, p. 388). The sixth printing of the DSM-II contained a new diagnosis, ‘sexual orientation disturbance’ (SOD) in place of ‘homosexuality’ (Stroller et al., 1973). ‘Homosexuality’ was considered to be an illness “if an individual with same-sex attractions found them distressing and wanted to change” (Drescher, 2015, p. 389). This feature normalized the practice of changing one’s sexual orientation in addition to seeking treatment to “become gay” if the individual was unhappy with identifying as heterosexual, though rather unlikely. The DSM-II, published in 1980, pathologizing identity that deviated from cisgender, heterosexual, and binary expression, which replaced SOD with egodystonic homosexuality (EDH). This template could essentially classify internalized racism and homophobia, in addition to body dysmorphia. Consequently, GENDER AFFIRMING ART THERAPY 24 EDH was removed from the DSM-II R revision. However, symptom of EDH remained in sexual disorder not otherwise specified (SDNOS), including “persistent and marked distress about one’s sexual orientation” (APA, 1987, p. 298). It was not until the DSM-5 that SDNOS was removed entirely. DSM-III and proceeding revisions formed a new category, Gender diagnoses. In 1980, the DSM-III added gender dysphoria in children, adolescents, and adults; gender identity disorder of children (GIDC), and transsexualism. DSM-II-R developed gender identity disorder of adolescents and adulthood, nontranssexual type (APA, 1987). The DSM-IV-TR, published in 2000, removed said diagnosis, and grouped transsexualism and GIDC under the umbrella diagnosis, gender identity disorder (GID) differentiating children and adolescent criteria. DSMIV (APA, 1994) and DSM-IV-TR (APA, 2000) moved GID to sexual and gender identity disorders, as well as renaming transsexualism as ‘gender identity disorder in adolescents or adults’ under sexual dysfunctions and paraphilias umbrella. The final and current revision, DSM5 (APA, 2013), GID was re-classified as gender dysphoria (GD), separating criteria for children, adolescents, and adults. This diagnosis drastically shifted from pathologizing identity, to focusing on the distress of incongruence between one’s preferred gender and one’s gender assigned at birth. To receive coverage or access to gender-affirming healthcare, individuals must present with said criteria. This highlights the controversy of the healthcare system, specifically in reference to transgender individuals, who may not meet full criteria for the diagnosis. Consequently, ethical decision making sometimes comes into question. Clinicians may provide diagnosis so they receive coverage, or individuals may express distress to receive diagnosis for coverage, a trend throughout history (Chang et al., 2018). The role of the psychiatric profession GENDER AFFIRMING ART THERAPY 25 has influenced society’s attitudes of the LGBTQ+ community, specifically impacting healthcare access and civil rights. WHO A leading agency in international health, World Health Organization (WHO), has also played a significant role in the stigmatization and pathologizing of sexual and gender identity as well as gender expression, specifically within in relation to the LGBTQ+ community. In 1948, WHO published the International Statistical Classification of Diseases and Related Health Problems (ICD), a manual utilized as a global standard for health. Prior to 1948, the ICD was utilized specifically for classifying mortality. The ICD-6 categorized ‘homosexuality’ under Mental, psychoneurotic and personality disorders under chapter V (WHO, 1948). Furthermore, ‘homosexuality’ was sub-categorized as a “pathologic personality” under “sexual deviation” clustered with various paraphilias. In the third revision of the ICD, ICD-8 (WHO 1965), ‘homosexuality’ was removed from the pathologic personality classification. This revision added ‘lesbianism’ and sodomy. ICD-9 (WHO, 1975) included ‘trans-sexualism,’ differentiating transvestism, referred to as ‘cross-dressing.’ Drescher (2015) suggests the revisions of the DSM by APA influenced the sudden adjustments in the ICD from ICD versions 9 and up. In 1990, WHO published ICD-10, delineating gender diagnoses and finally removed homosexuality, stating “sexual orientation by itself is not to be considered a disorder.” ICD-10 was the first of WHO’s manual to outwardly pathologize gender variance, introducing new disorders “uniquely linked to sexual orientation and gender expression.” These included sexual maturation disorder, ego-dystonic sexual disorder, and sexual relationship disorder, shifting conceptualization of gender variant individuals. The ICD-10 began moving away from pathologizing sexual orientation, gender expression, and gender identity, to pathologizing the GENDER AFFIRMING ART THERAPY 26 distress and impairment in functioning due to incongruence of a person’s preferred orientation, identity, and expression. Nevertheless, the manual continued to use labels such as “abnormality” labeling simple uncertainty as a “cause” (WHO, 1990). Revisions for the ICD-10 occurred over an almost 30-year timespan. WHO continued to classify being transgender as a mental disorder until the release of ICD-11 in 2019. The Human Rights Watch stated this would have a “liberating effect on transgender people worldwide” (Haynes, 2019), reframing GID as gender incongruence. Understanding the history of medical and mental health care of the LBGTQ+ community is crucial in order to fully grasp the toll this has taken on the community. Affirming Care and Considerations Helping professionals can play a vital role in supporting LGBTQ+ youth. WPATH states clinicians are “ethically obligated to act as affirming safe adults and advocates” (WPATH, 2012). WPATH has developed the SOC, a clinical guideline to gender affirming care. Affirming therapy “is an interpersonal process that recognizes and supports an individual’s unique gender identity and expression” (Darke & Scott-Miller, 2021, p. 10). The therapist needs to go beyond merely accepting gender diversity, understanding the complexity and uniqueness of issues and experiences of transgender, non-binary, and gender diverse youth. The clinician functions not only as a therapist for the LGBTQ+ youth, but an educator, advocate, and resource coordinator in order to meet the needs of the youth, as well as family unit as a whole. WPATH SOC WPATH is a multidisciplinary, international professional association focused on promoting “evidence-based care, education, research, advocacy, public policy, and respect in transsexual and transgender health” (WPATH, 2012, p. 1). Consequently, WPATH developed the SOC with the goal of assisting with “safe and effective pathways” to attaining and maximize GENDER AFFIRMING ART THERAPY 27 self-fulfillment, psychological well-being, and overall health. The SOC (WPATH, 2012) provides clinical guidance for health professionals working with transsexual, transgender, and gender nonconforming people based on expert professional consensus, research, and experience through a Western European and North American perspective. The overarching focus of the mental health section of the SOC emphasizes importance of competency of mental health professionals working with transsexual, transgender, and gendernonconforming people, regardless of the reason for seeking care. Mental health professionals can “provide support and promote interpersonal skills and resiliency in individuals and their families” (WPATH, 2012, p. 29) as they navigate societal gender-specific discrimination and prejudice. In addition, psychotherapy can provide instrumental assistance with the psychosocial experience of coming-out, exploring and examining gender identity and gender expression, as well as addressing the impact of minority stress and stigma on mental health. Consequently, affirming psychotherapy may provide assistance with management of other co-occurring illnesses, such as depression, anxiety, suicide, and gender dysphoria. WPATH (2012) has outlined tasks for mental health professionals working with gendernonconforming or transgender youth presenting with gender dysphoria, such as assessment, referral, and psychoeducation. Each task is further delineated by specific clinical guidelines. These can be found in section IV of the SOC (2012, p. 10). The SOC discusses the differences between gender dysphoria in children and adolescents, exploring “phenomenology, developmental course, and treatment approaches” (WPATH, 2012, p. 10) which highlights that there is “greater fluidity and variability in outcomes, particularly in pubertal children.” Mental health professionals should exhibit competency in irreversible, partially irreversible, or nonreversible treatment in order to support gender-nonconforming or transgender youth who wish to GENDER AFFIRMING ART THERAPY 28 seek said treatment. Furthermore, an understanding of appropriate language to use is essential. For example, individuals may experience feelings of dysphoria when discussing menses, breasts, and vaginal health. Therefore, using words such as menstrual suppression, top, bottom, etc. may help alleviate distress for the client. Consequently, it is essential that mental health professionals meet youth with acceptance, non-judgmental attitudes, and support because many gendernonconforming, transgender, and transsexual people “will present for care without ever having been related to, or accepted in, the gender role that is most congruent with their gender identity” (WPATH, 2012, p. 30). Mental health professionals may also assist an LGBTQ+ or gender-nonconforming person who seeks to make a social gender role transition or change their gender role through permanent affirming treatment. Individuals may “explore and anticipate the implications of changes in gender role” in addition to “pace the process of implementing these changes” (WPATH, 2012, p. 28). Affirming services can provide opportunities for safe exploration outside of the therapeutic environment to embody confidence and gain experience in the new role. For gender diverse youth who may wish to seek legal services, such as name change, mental health professionals can help youth and their family navigate these processes. Furthermore, clients are free to express themselves through behavioral exploration that is congruent with their identity through a safe and nonjudgmental therapeutic space, such as exploring preferred name and pronouns. For example, a mental health professional may investigate familial reactions to coming out, including who they may come out to and at what time to ensure their safety. Medical and gender role interventions impact the family unit, not just the client. Role of Counseling for the Family. GENDER AFFIRMING ART THERAPY 29 Research has established a definitive relationship between overall health in adulthood and familial acceptance towards their LGBTQ+ children (San Francisco, 2010). Specific caregiver behaviors that protect LGBTQ+ youth against suicidal thoughts and attempts, depression, and substance abuse include supporting their child’s gender expression and advocating for their child when mistreated. Furthermore, San Francisco State University (2010) found that LGBTQ+ adults exhibit higher levels of social support and self-esteem when family acceptance levels were high in adolescence. The study also found that LGBTQ+ young adults “were over three times more likely to have suicidal thoughts and to report suicide attempts” (San Francisco, 2010) who reported high levels of family rejection in adolescence compared to non-LGBTQ+ youth who reported high levels of family acceptance. Consequently, mental health professionals more often than not providing family therapy and support for family members in addition to the aforementioned client-specific care. It is common for caregivers to need time to process this change. Mental health professionals can help family members through this process and facilitate caregiver acceptance. Additionally, mental health professionals can help improve, enhance, or foster a supportive connection with their child. LGBTQ+ youth may explore and examine ways to effectively communicate with their family members. Typically, parents may go through a process of grieving over the perceived loss of the child they gave birth to as the LGBTQ+ youth begins to explore their preferred gender. For family members that may be struggling through this experience, mental health professionals can refer family members to adult services to better fit their needs. The therapist is essentially a liaison and/or part of the teen’s treatment team, as well as the family unit. Multidisciplinary Team. GENDER AFFIRMING ART THERAPY 30 Gender-nonconforming and LGBTQ+ youth and their family often work with a team of professionals that each play a significant part in the youth’s treatment. Professionals may include a behavioral therapist, psychiatrist, medical provider, nurse practitioner, speech-language pathologists, surgeons, and an endocrinologist. It is fundamentally critical that the mental health professional maintains a professional relationship and regularly consults with each member of the treatment team. Competency in the referral process, follow up process, and phases of treatment is crucial in order to help support family and LGBTQ+ youth. WPATH notes the SOC is meant to be flexible, in order to meet the needs of diverse health care for this community. Though these are considered flexible, the SOC “offer standards for promoting optimal health care” (WPATH, 2012, p. 2). WPATH recognizes there may be clinical departures due to lack of global resources; research protocol; “a patient’s unique anatomic, social, or psychological situation” (WPATH, 2012, p. 2); or “the need for specific harm-reduction strategies.” However, any divergence should be explained to the client and family and should be documented. It is evident that affirming care has complexities and uniqueness which require competency. Mental health agencies and organizations should undoubtedly address and adapt these standards in their ethical guidelines in order to ensure efficacy and safety in practice when working with this community. Art Therapy Literature with Gender Diverse and Transgender Youth Art therapy as an effective practice continues to grow in recognition amongst the health care profession. Art therapy has been shown to improve self-perception, emotional regulation, insight, and initiate behavior change (Malchiodi, 2016). However, there is a lack of literature and research about art therapy treatment with transgender and gender-diverse youth. Aforementioned in sections of this paper, there is currently only one book specifically addressing art therapy GENDER AFFIRMING ART THERAPY 31 considerations with this community. Additional pieces of literature address sexual orientation and couple transgender individuals with individuals whose sexual orientation is lesbian, bisexual, and gay sexual orientation. Furthermore, the American Art Therapy Association (AATA) does not currently have specific guidelines for art therapists working with this community to utilize in practice, nor do they acknowledge WPATH’s SOC, in addition to community challenges and treatment complexities. Though the context of existing literature was written and produced with different standards and conceptualization that reflected the level of acceptability prior to now, it is essential to examine and critique this research in order to prevent previous mistakes and highlight the significance of ethical and comprehensive care for transgender and gender-diverse people. AATA October of 2017 was the first time AATA specifically addressed LGBTQIA community, which was truly a response to sexual orientation change efforts. In this statement, AATA stated “The American Art Therapy Association unequivocally affirms LGBTQIA orientations are natural, positive, and moral variations of human sexual expression” (AATA, 2017), opposing sexual orientation change efforts and labeling them as unethical. Additionally, the statement outwardly expressed affirmation of the LGBTQIA community, supporting “therapeutic interventions that foster healthy development across the lifespan of LGBTQIA individuals, and equally admonishes treatment purported to cure or curb natural variations of sexual orientation, gender identity, or gender expression” (AATA, 2017). AATA then recognized The American Psychological Association, the American Counseling Association, The National Association of Social Workers, and the American School Counselor Association. While this statement was important to make, it missed the mark in many ways. There was a lack of differentiation between GENDER AFFIRMING ART THERAPY 32 gender identity, gender expression, and delineation of gender diverse and transgender individuals. First and foremost, transgender, genderqueer, and gender non-conforming are all terms related to gender roles as well as gender identity. Transgender “should only be used as an adjective and never as a noun” (The Trevor Project, n.d.). Gender identity and sexual orientation are mutually exclusive terms. Gender identity is the intimate, personal conception of one’s gender role, outwardly manifested by one’s gender expression. Sexual orientation refers to an individual’s romantic, emotional, spiritual, and/or physical attraction to another person (The Trevor Project, n.d.). Consequently, AATA solely addressing sexual orientation in this statement and ethical principles as well as briefly mentioning gender expression and identity, further adds to the confusion about said terms in addition to highlighting the gap in knowledge when working with gender diverse individuals. Moreover, AATA fails to acknowledge WPATH, the leading international agency that created and promotes standards of care when working with transgender and gender-nonconforming individuals. This statement was simply inadequate, which was followed up by an ethical consideration solely addressing sexual orientation. The AATA Ethics Committee followed up this statement with Appropriate Responses to Sexual Orientation document. This ethical guideline (2017) acknowledges that clients “may be uniformed or misinformed about sexual orientation and gender identity issues.” Interestingly, the principles states the desire to “support and advocate for appropriate treatment of individuals in the LGBTQIA community” yet the agency is devoid of the unique complexities of gender expression and identity, as well as the nuances of exploration, coming out, and challenges of transgender and gender-diverse individuals. Appropriate Responses to Sexual Orientation state the importance of art therapists finding “positive affirming ways to counsel individuals with GENDER AFFIRMING ART THERAPY 33 sexual orientation concerns” (AATA, 2017) highlighting the Multicultural and Diversity Competence principle (AATA, 2013). Sexual orientation is just one small component of an individual’s identity. Therefore, hyper focusing on sexual orientation essentially does a disservice to transgender and gender diverse youth, especially when AATA explicitly states the importance of advocating for appropriate and safe treatment of LGBTQIA persons (AATA, 2017). AATA’s ethical principles serve as an injustice for the transgender and gender-diverse community, omitting the prejudice and discrimination that contributes to mental health concerns. Furthermore, social transitioning, medical transitioning, and family impact are all components that are vital for art therapists to understand in order to effectively work with this community that simply supporting and acknowledging sexual orientation does not imply. Art therapists must demonstrate competency of this literature to effectively work with transgender and gender diverse individuals. Additional Literature The number of art therapy publications and research specifically addressing mental health needs, art therapy considerations, and community challenges for transgender and gender diverse youth are sparse. Additionally, existing literature have many problematic characteristics such as pathologizing transgender and gender diversity clients, erasure of the community’s experience, and problematic language. In 1970, “Art Therapy in the Diagnosis and Treatment of a Transsexual,” authored by Cohen (1974) and “The Use of Art in Understanding the Central Treatment Issues in a Female to Male Transsexual” by Fleming and Nathans (1979) were the first two pieces of literature that examined art therapy with transgender and gender-diverse individuals published in Art Psychotherapy. Though these articles utilized problematic language, GENDER AFFIRMING ART THERAPY 34 they differed from traditional psychotherapeutic and societal attitudes which focused on pathology. Two decades later, two additional articles were published in Art Therapy: Journal of the American Art Therapy Association in 1996. Sherebin’s “Gender Dysphoria: The Therapist’s Dilemma-The Client’s Choice. Discovery and Resolution Through Art Therapy,” explored her implicit biases and prejudice when working with a transgender client and, “In Search of an Accurate Likeness: Art Therapy with Transgender Persons Living with AIDS,” by Piccirillo, examined palliative art therapy with three trans people living with HIV/AIDS. Piccirillo continuously, whether deliberately or ignorantly, misgendered clients who explicitly stated their gender role by using non-preferred pronouns. Misgendering is defined as a “destructive form of social exclusion that generates and maintains both sexism and cisgenderism” (Ansara & Hegarty, 2013, p. 174), a form of erasure which increases psychological stress of transgender and gender diverse people, specifically impacting identity, sense of support, and depressed mood (McLemore, 2018). Piccirillo (1996) pathologized gender variance, labeling said variance as “repulsive” for some and even postulating transgender identity as a failure to individuate from the mother. Furthermore, when discussing client artwork, Piccirillo outwardly expressed her analysis and conclusion of client artwork without addressing the client’s own meaning of their image. In the same year, two additional articles by Bergin & Niclas (1996), art therapists examining treatment for children with gender identity disorder and Milligan (1996), an art therapist and mother of a child who was going through gender affirmation process, were published. Bergin & Niclas failed to address the relationship and impact between exhibited behavior and oppression faced by the participants, solely focusing on the behavior as opposed to GENDER AFFIRMING ART THERAPY 35 the context of behavior as the manifestation of marginalization. Miligan processed her own feelings and reactions through the art making process, yielding a better understanding of her child as “a whole being” (1996, p. 285). The 2000s saw a shift in literature which highlighted the lack of research and ways the binary gender system negatively impacted gender expansive and transgender individuals. In 2002, Barbee published an article discussing the cultural context and systems that impact gender diverse and transgender people, highlighting the narrative and voices of transgender people. The article also highlighted the role of therapist privilege, as well as organizational policies, specifically AATA, and discussed the historical stigmatization and pathologizing of transgender and gender expansive people. However, Barbee (2002) consistently demonstrated erasure and problematic language, such as “the transgender” or “a transgender.” Pelton-Sweet & Sherry (2008) built off of Barbee’s work, addressing the lack of research and competency. The authors also examined the integration of art therapy with sexual identity development with lesbian, gay, bisexual, and transgender clients, utilizing problematic language such as ‘transgendered.’ Education, training, and clinical guidelines focusing on the importance of competency when working with gender diverse and transgender individuals would acknowledge the term ‘transgendered’ as inappropriate. Consider the vignette posed by DiEdoardo, a trans female and San-Francisco based lawyer, “One day John Jones was leading a normal, middle-class American life when suddenly he was zapped with a transgender ray!” (Steinmetz, 2014). The issue with using the term ‘transgendered’ implies something has ‘been done to a person,’ contributing to some of the misconceptions of what it means to be transgender, such as transgender equates to surgery. The authors also missed the marked for the unique complexities transgender people experience. GENDER AFFIRMING ART THERAPY 36 In the same article, the authors discussed mental health concerns and the coming out process of LGBT clients yet failed to address transgender and gender diverse clients, demonstrating erasure of the community. More specifically, each citation referred to lesbian, gay, and bisexual clients solely, yet continued using the LGBT umbrella term. Furthermore, their references also exclusively focus on lesbian, gay, and bisexual sexual orientations, glossing over the coming out process for a transgender person within one paragraph. Consequently, this publication does not discuss the interconnection of coming out sexually and socially, which is a lifelong process that includes safety, not only emotionally but physically. For example, transgender individuals may need to process their sexual identity and how it aligns with their preferred gender role. Disclosing this information to a possible sexual partner can pose safety risks as well as additional health risks. Art therapists may need to aide transgender and gender diverse youth address and explore sexual preferences, as well as pleasure, specifically as it relates to their preferred gender role. Within the paragraph, Pelton-Sweet & Sherry acknowledge processing gender identity, yet the paper specifically discusses sexual orientation. Therefore, it is fair to assume there is confusion and a lack of education about the differentiation of terms as well as their implications in treatment. Albeit the authors address the lack of research and need for competencies when working with this community. Zappa, an Australian born gender-queer art therapist critiqued existing research and addressed the lack of research with transgender and gender diverse individuals in the United States within their qualitative study (2017), noting most literature is comprised of case studies and examples. Zappa additionally addressed an issue uncommon amongst publications. Most research conducted with transgender and gender diverse individuals is through a cisgender, binary lens, void of acknowledging the privileges the author or authors hold. Consequently, GENDER AFFIRMING ART THERAPY 37 “such research has led to a greater possibility for harm and exploitation, especially with regard to the pathologization of trans and gender-independent people” (Zappa, 2017, p. 130), highlighting the importance for researchers to “understand how they can contribute to the marginalization of trans people without complicating the gender binary” (Zappa, 2017, p. 130). Zappa (2017) also discussed how art therapy research has contributed to the oppression of people of gender diverse backgrounds, stressing erasure, misgendering, pathologizing of the community. Darke & Scott-Miller published Art Therapy with Transgender and Gender-Expansive Children and Teenagers, earlier 2021. This was the first publication in the field of art therapy that addressed art therapy as a primary intervention for this population through a genderaffirming lens. More specifically, the authors proposed affirming considerations mentioned in this paper, as well as art therapy interventions that help this population effectively process transitioning as well as self-expression. This paper essentially extends and builds upon Zappa, Darke, & Scott-Millers notions, putting forth a gender affirming art therapy approach. Conclusion It is crucial that art therapists understand the historical and contextual nature of the civil rights challenges, prejudice, and stigmatization of the transgender and gender diverse community, as well as how these issues create or exacerbate mental health concerns. There is currently a lack of research and literature with transgender and gender expansive youth in the field of art therapy. Existing literature utilizes problematic language and erasure of the community’s experience that results in an oppressive nature. Art therapy with gender diverse and transgender individuals has the potential to provide “practitioners and clients the unique potential to disrupt social hierarchies” (2017, p. 129). However, AATA does not currently have considerations for art therapy when working with gender diverse and transgender youth. Existing GENDER AFFIRMING ART THERAPY 38 literature is few and far between, exuding erasure, problematic language, and discrimination towards the community. Examining and critiquing this literature provides an opportunity to inform the field of art therapy’s past mistakes as well as drawing attention to the importance of a gender affirming art therapy approach to effectively, competently, and culturally provide treatment to gender diverse and transgender youth. GENDER AFFIRMING ART THERAPY 39 Section III: Methodology This section discusses the framework for the art therapy curriculum presented in Appendix A. The curriculum focuses on providing a gender affirming approach to art therapy with transgender and gender diverse youth. This 8-week program addresses mental health concerns and community experiences in order to foster a sense of social support, resilience, and self-esteem amongst participants. The structure is modeled after the teen group at Nationwide Children’s Hospital’s THRIVE Gender Clinic, serving transgender and gender diverse youth in Columbus, Ohio developed and created by Heather Thobe, Tina Mason, and Lourdes Hill. Target Audience The curriculum is designed to benefit transgender and gender diverse youth. Ages may range from 14-18. This group is intended as a support group and does not suffice as the sole treatment for gender diverse and transgender youth, especially due to the limited number of weeks covered. More specifically, this group is for a client who is 14-18 years of age and is wanting to start gender affirming medications but has not yet for some reason. Reasons may be lack of caregiver acceptance, other more pressing mental health challenges that are the focus of treatment, etc. Participants will be screened for appropriateness and grouped together pending where they are in their transition process, so that members of the group have a similar shared experience. This is to ensure safety of the client, therapeutic relationship, and respect of the family’s pace. Though the curriculum is intended for trans and gender diverse youth, practicing art therapists may benefit from the curriculum structure and this paper, which provides a gender affirming art therapy approach. GENDER AFFIRMING ART THERAPY 40 Curricular Structure The curriculum is modeled after Nationwide Children Hospital’s THRIVE Gender Clinic, (see Appendix A). The program is structured to provide information specific to the transgender and gender diverse experience. Each week’s psychoeducation and objectives is sequenced. For example, group members learn and hone emotional regulation techniques in week 2 in order to process potentially traumatic or triggering information in week 5. See page 49 for program outline. Group Facilitator Considerations for Affirming Therapy First and foremost, it is recommended that clinicians must consistently and conscientiously engage in self-reflection concerning personal biases, beliefs, and attitudes about gender. Group facilitators are also encouraged to seek weekly supervision. Supervision is essential, especially to art therapists who have limited experience with this population, in order to process any encounters of unfamiliarity or personally triggering that were not made conscious previously. Art therapists implementing this curriculum exhibit and maintain competency in WPATH’s SOC, discussed in the affirming care considerations section of the literature review. The art therapist must also demonstrate aptitude in the contextual history of transgender and gender-nonconforming civil rights issues, mental health care, and societal prejudice. It is also suggested that art therapists display gender inclusivity at the outset of group such as modeling and discussing preferred pronoun usage. Art Therapy The group’s original format was developed through a behavioral health and counseling lens, and this paper posits an art therapy adaptation. The benefits of an art therapy adaptation are multifold. In art therapy, the creative process is healing, providing an additional layer of self- GENDER AFFIRMING ART THERAPY 41 exploration that talk therapy cannot provide. The art product can supply a “tangible piece that can contain the personal perspectives of the art maker” (Darke & Scott-Miller, 2021, p. 140), encouraging active participation in therapy. This metaverbal approach “can engage, inspire, and influence clients” through metaphorical imagery, presenting “new ways of perceiving a situation or experience, and enable the therapist to avoid being overly confrontational or prescriptive” (Moon, 2007, p. 10). Transgender and gender expansive youth come to therapy seeking safety and refuge in order to process the constant, aggressive, and damaging explicit and implicit societal messages. Art therapy can provide a nonthreatening way to express associated thoughts, feelings, and behaviors, as well as find safely engage in self-discovery through the metaphorical nature of art making. As clinicians of a cisgender-dominated field, art therapists and therapists in general, experience privilege which can impact the therapeutic relationship. When the art therapist creates alongside group participants, “the act of working together encourages a relationship that goes deeper than words” (Moon, 2007, p. 12). Furthermore, the art making process offers a sense of shared experience between group participants and the art therapist. Art therapy offers a “creative means through exploring different media to connect inner and outer worlds and navigate an exploration of identity” (Darke & Scott-Miller, 2021, p. 15). Consequently, the therapeutic relationship, one of the most important components to therapeutic change, is formed on a deeper level. This characteristic offers an opportunity, unlike any presented in traditional talk therapy, for the art therapist to engage in empathic understanding, breaking down hierarchical barriers. Theoretical Supports The theoretical underpinnings of the curriculum are Cognitive Behavior Therapy (CBT), Motivational Interviewing (MI), and client-centered approaches. Aforementioned in the mental GENDER AFFIRMING ART THERAPY 42 health section of the literature review, transgender and gender diverse youth experience prejudice and stigma that impacts mental and behavioral health. In order to manage these feelings and experiences, transgender and gender diverse youth benefit from building resiliency, acceptance or support, as well as developing a set of effective and helpful coping tools. Factors that help facilitate transgender and gender diverse youth include social connectedness, transgenderaffirmative social support, and self-advocacy (Austin et al., 2016). The person-centered component provides unconditional positive regard for participants, creating a nonjudgmental therapeutic space to foster validation and acceptance. It is likely that transgender and gender nonconforming youth experience a threat to their “sense of safety, power, and control over their lives” (Austin et al., 2016). Transgender and gender diverse youth who experience social connectedness within a trans community experience “increased comfort with a person’s transgender identity and better behavioral health” (Austin et al., 2016, p. 3). MI is a counseling approach rooted in person-centered philosophy. Consequently, the MI component builds on abilities, competencies, resources, and strengths of participants and through a time-sensitive approach. More specifically, MI elements “support members’ self-efficacy, mainly encouraging members to use the resources they already have to take necessary actions and succeed in changing” (Corey, 2016, p. 438). MI promotes resilience with participants as well as aiding group members to identify motivation for behavior change. Furthermore, the group facilitator can help highlight group members’ autonomy in decision making, as well as fostering a sense of competence in making therapeutic change. The CBT element provides psychoeducation about the reciprocal relationship between thoughts, feelings, behaviors (CBT triangle), and body reactions to improve emotional regulation and identification. More specifically, this CBT approach is grounded in the consideration of the GENDER AFFIRMING ART THERAPY 43 pervasiveness and consequences of stigmatization and prejudice of transgender and gender diverse community. Specific, affirming considerations to behavioral change through the CBT with transgender and gender diverse youth include learning how to identify environmental components such as where, when, as well as with whom these changes can occur in order to ensure safety. Conclusion This paper presents an 8-week gender affirming art therapy support group for transgender and gender diverse youth, aged 14-18. The approach is modeled after THRIVE’s adolescent group for trans and gender nonconforming adolescents at Nationwide Children’s Hospital in Columbus, Ohio. Group members will be screened for appropriateness and placed with other youths who are in similar phases of physical intervention during the transition process. The theoretical approaches include CBT, MI, and person-centered. Specific gender affirming group facilitator considerations include engaging in self-reflection to process personal attitudes, beliefs, and biases about gender, along with demonstrating competency of WPATH’s SOC, as well as exuding gender inclusivity at the outset of group. The following section will discuss in detail the week-by-week curriculum. GENDER AFFIRMING ART THERAPY 44 Section IV: Curricular Guide The following section presents the facilitator’s guide to an 8-week, closed art therapy group specifically working with transgender and gender diverse youth. The proposed curriculum is intended for gender and diverse youth aged 15-18. The following program should be implemented by a licensed art therapist with extensive knowledge, training, and experience with gender diverse youth. This is an essential component of the art therapist in order to ensure competency of the intricacies of working with this community to maintain client safety as well as foster support. An art therapist wishing to utilize this program and/or directives should only do so when the aforementioned component is met in addition to processing personal biases in relation to gender, sexuality, and working with trans and gender diverse youth. Additionally, clinicians should seek supervision in order to explore, as well as reflect, said issues. Each session is composed of four parts, an ice breaker, psychoeducation, directive, and additional activities to supplement information learned such as homework. The icebreakers coincide with the objective of the group and provide opportunities for group rapport building. Psychoeducation addressed within each session include but are not limited to the following: gender identity, gender expression, sexual orientation, minority stress, and social supports. The art therapist should refer to the terminology and literature view for more information about these topics. As mentioned in the glossary of this paper, these terms are everchanging; therefore, the art therapist should review current terminology and keep up to date with current changes prior to and during the implementation of this program. Facilitating discussion about these subjects is essential to support gender diverse and trans youth in processing and understanding the self, the community, and how these components are experienced within societal norms. It should be noted that the following program is merely an introduction for transgender and gender diverse youth GENDER AFFIRMING ART THERAPY 45 into the vast intricacies and nuances of what it means to be a part of this population and community. It is encouraged and recommended that clients seek additional mental health support. Furthermore, this program is considered a supplement to an art therapist’s practice and should not be the sole resource utilized when working with this population. The goals and objectives within the curriculum address community needs. More specifically, the ultimate goal of this program is to help clients strengthen protective factors for mental health and cultivate resiliency skills in order to manage stressors unique to this population such as the intersectionality of race, gender, and sexuality in relation to societal prejudice and discrimination. Additionally, the program provides a safe space for clients to engage in exploration of their gender identity and gender expression, highlighting the importance of identifying social and communal supports. It should be noted that supplemental documents are pulled from several resources. Therapist Aide, Hues, Trans Student Educational Resources, The Trevor Project, and Action Canada for Sexual Health & Rights are among the many electronic resources used. An electronic version of The Gender Quest Workbook, by Testa & Coolhart (2015) is also utilized. The program is written with flexibility to adapt sessions in order to meet the diverse needs of clientele within this population. For clients who may experience hearing impairments or clients that are considered English as Second Language (ESL), clinicians should obtain appropriate translation services. The clinician is responsible for obtaining this information during the screening process. It should be noted there is a strong relation between individuals with Autism Spectrum Disorders and individuals who identify as gender diverse and transgender (statistic). Consequently, art therapists will need to consider tactile defensiveness and adapt sessions as needed. Laptops can be provided with electronic versions of paper handouts. GENDER AFFIRMING ART THERAPY 46 Additionally, materials such as wet media may need to be adapted in order to meet this population’s needs. For individuals managing physical or motor deficits, clinicians must obtain adaptive art materials. This information should be obtained during the screening process and materials should be present at the outset of group. Assistance can also be provided upon client request with writing and reading. ASD & Gender Dysphoria Current literature suggests a significant overlap between individuals with ASD, gender variance, and gender dysphoria (Janssen et al., 2016). Research suggests “a bidirectional relationship; that is, individuals presenting with gender dysphoria are more likely to have cooccurring diagnosis of ASD, and individuals presenting with a diagnosis of ASD are more likely to have a co-occurring diagnosis of gender dysphoria” (Janssen, 2018, p. 122). Consequently, it is important for an art therapist to understand how to navigate the intricacies of gender identity development with someone with ASD to ensure they meet the unique considerations and needs of this niche community in a group setting. Furthermore, an art therapist working with the trans and gender diverse population should understand how to differentiate between symptoms of ASD and symptoms of gender dysphoria. From the author’s personal experience with implementing psychoeducation groups to the trans and gender diverse youths, at least 2-3 members of an 8 or less group were managing ASD and receiving counseling services through the autism center at the children’s hospital. This is noted in order to highlight how the implementation of this group may be impacted in relation to content exploration and group dynamics. Individuals with ASD may experience impaired theory of mind, social-emotional reciprocity, and persistent deficits in social communication. Therefore, exploring topics such as gender fluidity, gender identity, and gender expression may pose challenges for group members GENDER AFFIRMING ART THERAPY 47 with ASD. Additionally, understanding social cues of the way in which information is processed and the conceptualization of gender may impact other group members. The following case vignette presents an experience observed by the author during a psychoeducation group between a trans masculine group member diagnosed with ASD & gender dysphoria (he/him) with a nonbinary group member (they/them/he/she). It highlights the necessity of why an art therapist must demonstrate competency not only with treatment for individuals exploring with gender, but also with individuals with co-occurring ASD. Case Vignette During a group discussion about gender expression, including pronouns and gender fluidity, a group member was sharing how their experience of gender expression changes daily. The group member discussed that their pronoun usage may change that day as well, and asked that during check in, group members share their pronoun preferences at the outset of group so that they may experiment with pronouns. A different group member began challenging the validity of their experience. From the author’s observation, it appeared as though the comments essentially were rooted in confusion and a desire to understand more. The group member then stated, “That doesn’t make any sense, how can you just be a boy one day and then be a girl?” The nonbinary group member became upset, and this caused an argument between several group members, which then spilled into the following session. Nevertheless, the individual with co-occuring ASD did not pick up on the social cues to adjust language, commentary, or questioning, which a neurotypical group member may have noticed. Ultimately, this resulted in group facilitator intervention and redirection. GENDER AFFIRMING ART THERAPY 48 Art Therapy with Transgender and Gender Diverse Youth: Gender Affirming Considerations The Official Facilitator’s Guide Program Goals & Objectives GOAL 1: Clients will improve positive identity a. Objective 1: To learn about and differentiate gender identity, gender expression, and sexual orientation b. Objective 2: To explore individual strengths and positive characteristics GOAL 2: Clients will be presented with psychoeducation about the transgender and gender diverse experience a. Objective 1: To expand understanding of terminology related to the transgender and gender diverse experience. b. Objective 2: To learn about intersectionality as it relates to the gender diverse and transgender experience GOAL 3: Clients will build resiliency skills in order to process, withstand, and manage community-specific adversity a. Objective 1: To develop individualized and effective coping strategies in order to manage life stressors. b. Objective 2: To identify and understand the importance of social supports GENDER AFFIRMING ART THERAPY 1. 2. 3. 4. 5. 6. 7. 8. Curricular Outline Week 1: Opening Group/ Introductions a. Psychoeducation: i. Structure of group, group goals, expectations, confidentiality b. Intervention: i. Engage in brainstorming and sharing of goals c. Additional: Resilience Scale Week 2: “How I Cope and Building Connections” a. Psychoeducation: i. emotion scaling, coping tools b. Intervention: i. Draw on Feelings c. Additional: Coping toolbox Week 3: “Who I am” a. Psychoeducation: i. Identities, many parts of self, intersectionality, minority stress theory b. Intervention: i. Inside Me vs. Outside me c. Additional: “My gender” activity (Gender quest) Week 4: “My Gender Journey” a. Psychoeducation: i. Gender unicorn, Galaxies, Genderbreads, Oh My! b. Intervention: i. We’re going on a trip Week 5: “Messages I am hearing” a. Psychoeducation: i. Micro aggressions, CBT Intro, & Radical Acceptance b. Intervention i. I am in Control of the Messages I hear, and First it Starts with ME Week 6: “You’ve Got a Friend in Me” a. Psychoeducation: i. Self-Worth & Social Support b. Intervention: i. Ideal Self Week 7: “Resilience is Key” a. Psychoeducation: i. Putting it all together: Managing Stress in Various Aspects of your Life through Resilience b. Intervention: i. Suit of armor and/or shield Week 8: “So long, Farewell” a. Psychoeducation: i. Community & Resources b. Intervention: i. Pass it On c. Graduation: snack, Resilience Scale 49 GENDER AFFIRMING ART THERAPY 50 Session 1 Opening Group/Introductions 1.A. ICE BREAKER: “Community Bingo” (15) Purpose: to improve conversation skills, rapport building, following directions, group participation Materials: • Bingo Sheet (See Appendix B) • Pens/pencils Directions: • Present icebreaker to the group: “We are going to get up, get moving, and get to know one another! • You will work your way around the room and attempt to get a BINGO. The goal is to get 5 spaces in a row, diagonally, horizontally, or vertically). In order to get BINGO, you will need to ask group members if the “Get to know you” statement applies to them and write their name on the line. You may only have ONE person’s name per statement in order to receive BINGO. o Example: Question: “Do you like to cook?” Peer response: “Yes!” *write name down, ask 4 different people statements on the bingo sheet* 1.B. PSYCHOEDUCATION: “Group Structure (30 min) Purpose: build group structure, understanding flow of group, ethics of group Materials: • Group Agenda • Confidentiality agreement • Binders • Computer paper • 2D Drawing Materials: pens, pencils, markers • Domains of Resiliency (See Appendix C) Topics of Discussion: • Agenda o Discuss meeting time and location (Tuesdays 5:30-7, main campus) o Provide agenda and review topics for each week o Discuss the overarching goal of resiliency building  Pass out and discuss domains of resiliency o Request that members wait to exchange contact information at the outset of group. Developing relationships outside of group may hinder group cohesiveness. • Domains of resiliency o See Appendix C. This is merely a guide for the facilitator. The rational does not have to be read word for word. • Binders o Provide group members with binders, 2D drawing materials to decorate cover page GENDER AFFIRMING ART THERAPY • o Discuss function of binder for group and that they will stay with facilitator in a locked cabinet Confidentiality Agreement o Discuss confidentiality with group o Offer opportunities for group members to elaborate on why confidentiality is important 1.C. DIRECTIVE: “Why are we here?” (20 Minutes) Purpose: to build group and facilitator rapport, establish group rules & expectations Materials: • Large wall post-it • Markers • Candy basket Directions: • Discuss importance of group rules • Collaboratively create group rules on large wall post-it. Candy can be provided as an option to those who participate to improve engagement and reinforce those for offering rules. 1.D. ADDITIONAL: Group Measures (20 minutes) Purpose: to obtain baseline data utilized to demonstrate efficacy of group Materials: • Resiliency Scale (See Appendix D) Directions: • Present and discuss importance of scales to group. Offer additional assistance such as reading aloud, writing, and/or any other accommodation needed. Collect scales upon dismissal 51 GENDER AFFIRMING ART THERAPY 52 Session 2 How I Cope & Building Connections 2.A. ICE BREAKER (10): “Paired Interviews” (15 min) Purpose: to improve conversation skills, rapport building, following directions, group participation Materials: • Interview questionnaire (See Appendix E) • Pencils • Clipboards Directions: • Present icebreaker to the group: “Now that we all have met, we are going to get to know each other a little better!” • As you all came into group today, you chose a number out of a container (any kind). You will need to find the group member with the same number and that will be your partner for this activity. You will follow the questionnaire found in your folder under session 2 and complete the activity together. When finished, you will present to the class about your partner. 2.B. PSYCHOEDUCATION: “Emotion Scaling & Coping Tools” (35 min) Purpose: to improve self-awareness, develop effective coping tools Materials: • Emotion Scale Worksheets (See Appendix F) • White board • Dry Erase Markers • Coping Tools List Topics of Discussion: • Emotion Scaling o Discuss how emotions can occur on a scale, from mild to intense. Discuss the importance of identifying intensity of emotions in relation to calming down. o On the white board, create a scale from 0-5 using the format of the Emotion Scale Worksheet (level, descriptor, what it looks like). Walk group members through the emotion happy as an example on the emotion scale. • Move to 2.C Directive. Once this is completed move to Coping tools. • **Coping Tools o Discuss coping tools. Talk about the importance of using different types of coping tools as the emotion intensifies. Ex: Emotion on level 5 may need a physical activity, break, etc. o Instruct group members to select an emotion they have a challenging time managing. Provide time for group members to fill out an emotion using the scaling worksheet, fill in word descriptor, what it looks like, and appropriate coping tool 2.C. DIRECTIVE: “Draw on Feelings” (30 min) GENDER AFFIRMING ART THERAPY 53 Purpose: to improve self-awareness, identify feelings in the body, rapport building, emotional identification Materials: • Large wall post-it w/body outline drawn • Markers • Candy basket Directions: • Around the wall you will notice several body outlines. With the markers on the table, use lines, shapes, colors, etc. to indicate where you feel the emotion in the body. You can start with whatever emotion you would like but try to make a mark on each of the emotions! When everyone is finished, those who feel comfortable sharing may show the group which illustration was theirs on each of the outlines. Processing Prompts: • After looking at all of the body outlines, which one stands out the most? • Do you notice any themes of color for each of the emotions? • Which emotion was the easiest/most challenging to detect in the body? • Which emotions are the easiest/most challenging to manage? • What similarities do you see between the body outlines? **Upon completing of directive, move to coping tools under 2.B 2.D. ADDITIONAL: “Coping Toolbox” (5 min) Purpose: to develop individualized coping tools, build, and improve resiliency strategies Materials: • Coping Toolbox (See Appendix H) Directions: • For this week’s home project, you are to create your own toolbox. You may gather materials and put them in a box, or you may fill out the worksheet provided. You are to utilize your toolbox throughout the week as you GENDER AFFIRMING ART THERAPY 54 Session 3 Who am I? 3.A. ICE BREAKER (10): “Common Ground” (10 min) Purpose: to improve conversation skills, rapport building, following directions, group participation, build community connectedness Materials: • None Directions: • Present icebreaker to the group: “Though gender is important, it is just one of the many qualities that make us who we are. So today, we are going to find some common ground. We will have a group member start by sharing something about themselves, whether it is their favorite food, what they like to do, music they listen to, etc. If something the group member says relates to you, you say “common ground.” Whoever says “common ground” first, will start sharing their likes/dislikes, and so on and so forth. We will do several rounds!” o Whenever it is your turn to start, please share your coping toolbox briefly 3.B. PSYCHOEDUCATION: “Intersectionality and Parts of the Self” (30 min) Purpose: to improve self-awareness, building components of the self-outside of gender, understanding uniqueness and impact of where parts of the self, overlap, improve resilience Materials: • Social Identity Groups (See Appendix I) • Identity Signs Facilitator Guide (See Appendix J) • Intersectionality Diagram (See Appendix K) Topics of Discussion: • Social Identity Groups o See Appendix I. Follow facilitator directions. Discuss identity group definitions and have clients fill out their own wheel in preparation for Identity Signs Activity. • Identity Signs Activity o Be sure to hang up identity signs while clients are completing their wheel. Utilize the facilitator guide (See Appendix J) • Intersectionality & Minority Stress Theory o After completing the Identity Signs activity, bring group back together for a discussion about intersectionality and provide the intersectionality diagram (See Appendix K). Work with the group on highlighting where identities overlap. Discuss how the overlapping areas may lead to experiencing prejudice, discrimination, and racism. Highlight the importance of developing resilience in order to combat these vulnerabilities, drawing back to the purpose of the group. 3.C. DIRECTIVE: “Inside Me vs. Outside Me” (30 min) Purpose: to improve self-awareness, safe exploration of parts of the self, group cohesiveness Materials: • Pre-cut magazine clippings (images, words, phrases, etc.) • Markers • Glue Sticks • Drawing Paper (8x10) GENDER AFFIRMING ART THERAPY 55 • Magnets Directions: • Take a piece of paper and draw a vertical line, top to bottom, splitting the paper in half (hamburger style) • Using the magazine clippings, you will be creating a collage of images on both sides. o On the left, create a collage of images that represent who you are or how you feel on the inside. This may be hidden from others, or maybe your best friend knows these parts of yourself. o On the right, create a collage of images that represent who you are on the outside. This may be a different representation of yourself, whether it be from your parents, school peers etc. o These collage images may be different from one another, and that is okay! We may act different in front of others for reasons such as safety, trust, etc. We will process it further when images are finished. You may add any other additional images, words, or phrases that you do not find in the magazine pile! • When finished, for those that feeling comfortable, please hang up your piece on the whiteboard using the magnets provided. Processing Prompts: • Describe your image, both left and right. • What similarities do you notice? • What differences do you notice? How come? • What would happen if some of the “inside me” pieces moved to the right side? o How would you do this? Would you need assistance? • Is there a person or place where you feel comfortable showing your “inside me?” • What would it take to make both sides more congruent? 3.D. ADDITIONAL: “My Gender” Activity (5 min) Purpose: to identify ways to explore gender expression, identifying ways to explore safely Materials: • “My Gender” Activity from Gender Quest Workbook found on page. 19-23 (See Appendix L) Directions: • For this week’s home project, you are to complete the “My Gender” activity. Please be mindful of where, when, and who you complete this with in order to ensure safety. Bring the answers to the next session. You may also take a picture and complete the information on your phone. This will help prep you for next week’s session! GENDER AFFIRMING ART THERAPY 56 Session 4 My Gender Journey 4.A. ICE BREAKER: “Roger That!” (10 min) Purpose: to build group rapport, improve problem solving and group adjourning Materials: • 2D objects o Blocks, cars, cones, plush toys, bandanas, buckets Directions: • “As you can see, there are two obstacle courses. You will be divided into two teams, competing to see who can finish the course first. A team member of each team will compete one at a time, I (facilitator) will be timing each round. Whichever team member has the least total time completing the course wins. BUT! There’s a catch. The individual who is taking their turn will be blindfolded. Your team will need to work together to instruct the team member safely through the obstacle course WITHOUT touching any objects. If a team member touches an object twice within their round, they must start over! 4. B. PSYCHOEDUCATION: “Unicorns, Galaxes, Genderbreads, Oh My!” (30 min) Materials: • Trevor Project Key Terms (See Appendix M) • Unicorn Gender PDF (See Appendix N) • Genderbread PDF (See Appendix O) • Gender Galaxy (See Appendix P) • Sexuality Galaxy (See Appendix Q) • Galaxy Activity Instructions (See Appendix R) Topics of Discussion: • Provide the Trevor Project’s Key Terms (See Appendix M) and display gender diagrams (See Appendix N-Q) on the whiteboard. Explore PDFs with group members • Reference #2 (without drawing), 3, 4, & 5 off the Galaxy Activity Instructions (See appendix R). o **Though the instructions specifically address the gender/sexuality PDFs, clinicians should generalize the identified questions so that the discussion applies to all four images. 4.C. DIRECTIVE: “We’re Going on a Trip” (50 min) Purpose: to provide opportunities for safe exploration of gender identity, gender expression, sexual orientation; emotional regulation, improve self-awareness, build community connectedness Materials: • 2D drawing and painting materials o Paint (any kind), brushes o Colored pencils, oil pastels, markers, pencils • Multimedia paper • Galaxy Activity Instructions (See Appendix R) GENDER AFFIRMING ART THERAPY 57 Directions: • Adaptation from #8 of Gender Activity Instructions: Imagine you are a space traveler (like the rocket ship and robot within the galaxies). Create an image of your own story of planetary and space exploration. o Make clear that they can use the images to facilitate their learning and selfdiscovery about gender and sexuality. Emphasize that there is no one story; that there are an infinite number of stories that could be created individually and will be created by the diversity of experience within your classroom (p. 1) Processing Prompts: • Describe your image and/or journey. • What has been the most difficult/most rewarding part so far? • Did you have a crew or is this a solo trip into space? • What would you tell yourself prior to starting the journey? • Are you traveling in a vessel? What is it made out of? Do you have enough supplies? • How has your journey impacted your life thus far? • How do you know you have reached your destination? What does that look like? o How or what steps will you take to get there? 4.D. ADDITIONAL: Closing Remarks (5 min) • Reference Educator Answer Key (See Appendix R on page 1) GENDER AFFIRMING ART THERAPY 58 Session 5 Messages I am Hearing 5.A. ICE BREAKER: “My Telephone” (10 min) Purpose: to demonstrate how small misconceptions can have an impact on an individual, build group rapport, Materials: • Strips of paper • Makers Directions: • Line up chairs in a long row facing the back of the room prior to session starting. Have strips of paper and markers on top of each chair. Each client should have their own chair and marker. • “We are going to play a game of telephone. The first person will come up with one long sentence. It can be about anything. They will write it down on the slip of paper. The second person will say “pst” and that is the cue for the person sitting in front of you to turn around. They will have 3 seconds to read the strip of paper before the first person removes their strip. The second person will then write down the message on their piece of paper. The process is repeated until all of the operators have written a message. Afterwards, we will compare.” • Rules: no talking, you cannot turn around until you are notified by the person behind you. 5. B. PSYCHOEDUCATION: “Microaggressions, CBT, & Radical Acceptance” (35 min) Materials: • The Cognitive Model (See Appendix S) • What Are Core Beliefs (See Appendix T) • Distress Tolerance (See Appendix U) Topics of Discussion: • Microaggressions o Ask group members if they have ever heard the word microaggression and ask group members for their definition. o “If you are comfortable, please use a whiteboard marker and write on the board a microaggression you have experienced.” Thank the group members who have shared and explore feelings associated with these experiences. o Define Microaggression as an action, statement, or situation that can be unintentional, subtle, or indirect which discriminates against individuals of a marginalized group. • CBT o Move to passing out the CBT intro sheet (See Appendix S) and follow suit. Discuss the CBT triangle, emphasizing how we perceive a situation impacts how we behave. o Move to the Core Beliefs sheet. (See Appendix T) and follow the guide.  Note that our core beliefs impact the way we behave, think, and feel about situations. Negative core beliefs may lead to unhealthy behavior and consequences such as substance use, unsafe sexual relations, etc. o Note the fact that some of these things we cannot control and to feel anxious, angry, and/or upset is valid especially when societal discrimination and prejudice GENDER AFFIRMING ART THERAPY 59 occurs rampantly against the transgender community. So, what do we do if we can’t control what is going on around us? This is where distress tolerance and radical acceptance comes into play. • Radical Acceptance o Introduce the DBT skill of distress tolerance (See Appendix U). Highlight needing to build distress tolerance as a protective factor of trans youth’s mental health. Draw group back to the microaggressions and messages heard, emphasizing that we cannot control someone else’s behavior, only our own. o Discuss the prevalence of prejudice and discrimination within the community. Note the importance of accepting and moving forward will lead to less anxiety, anger, and sadness along with social support and coping skills. • TAKE AWAY FROM SESSION: Accepting doesn’t mean making the problem okay or the norm. There are ways to fight discrimination, prejudice, and violence through action such as voting, joining an LGBTQIA+ club, & improving your core beliefs so that you can behave & feel in ways that are congruent with your sense of self. 5.C. DIRECTIVE: “I have Control over the Messages I Hear, and First that Starts with Me” (45 min) Purpose: to improve distress tolerance skills, challenge negative core beliefs, build healthy coping alternatives Materials: • Small, cardboard boxes from Michaels o If this isn’t allotted in the budget, you can utilize cardstock and print out/cut instructions to fold paper into a box • 2D materials o Markers, colored pencils, crayons, sharpies • 3D materials o Tempera paint o Paint brushes o Gems, ribbon, feathers, etc. • Glue, magazine clippings • Computer paper cut into strips Directions: • Today you will make a positive affirmation box. You can decorate the box as you please. • Once finished, you will write at least 10 either positive affirmations and/or core beliefs and place them in the box. Think of a safe place you would like to put this box at your house and utilize the box throughout the week. Processing Prompts: • What 10 items did you come up with? • How easy/hard was it to come up with 10 items? • Where will you put the box? • What barriers may you experience to using the box? • When will you use the box? • Do you think it will be easy/hard to go to the box? • What happens if the box is not around when you need it? GENDER AFFIRMING ART THERAPY 5.D. ADDITIONAL: None 60 GENDER AFFIRMING ART THERAPY 61 Session 6 You’ve Got a Friend in Me 6.A. ICE BREAKER: “The You Game” (10 min) Purpose: to improve self-esteem, engagement in group adjourning Materials: *The number of dice, player pieces, and gameboards depends on the number of clients* • Dice • Player pieces (can utilize anything from a game including monopoly, trouble, clue, etc.) • The You Game (See Appendix V), laminated Directions: • If possible, split group members into teams of 4, no less than 3 per team. • “You will be playing The You Game. Choose a player piece to represent you and put your piece on the words Start. Read the directions as a group and begin.” 6. B. PSYCHOEDUCATION: “Self-Worth & Social Support” (40 min) Materials: • Social Support (See Appendix W) • Strengths Exploration (See Appendix X) Topics of Discussion: • Social Support o Pass out the Social Support PDF (See Appendix W). Discuss the importance of social support as a domain of resilience. Talk about how social support improves mental health, security, greater life satisfaction, and improved self-esteem. Go through the different types of social support & ways to improve it. Have group members fill out the remainder of the worksheet  Highlight that the number one protective factor against suicide is family acceptance. Facilitators should understand though that families may be a source of stress as often many clients may be ousted by families or struggling to manage transitioning/coming out with family members. Discuss the importance of seeking additional mental health support from a qualified professional to process these nuances.  Facilitators should explore outside social supports for those who may be experiencing challenges in relation to support with their immediate families. • Self-Worth o Discuss the importance of self-worth and self-esteem as protective factors for mental health. o Pass out the Strengths Exploration worksheet (See Appendix X) and follow the directions. 6.C. DIRECTIVE: “Ideal Self” (40 min) Purpose: to improve self-esteem, identify positive character traits, assess motivation to change Materials: • 2D drawing paper • 2D materials o Markers, crayons, colored pencils, oil pastels GENDER AFFIRMING ART THERAPY 62 Directions: • “You are going to be looking at who you are and who you want to be, your ideal self. Turn your paper so that the layout is horizontal and fold your paper hamburger style. On the left, you will create who you are now using imagery, lines, shapes, words, etc. On the right-hand side, you will create your ideal self, using imagery, lines, shapers, words, etc. Processing Prompts: • Describe your image • What are the differences between the two sides? • What are the similarities between the two sides? • What are the barriers to becoming your ideal self? • What are most excited for when thinking about your ideal self? • What fears do you have about becoming your ideal self? • On a scale of 1-10, how likely will you become your ideal self? 6.D. ADDITIONAL: None GENDER AFFIRMING ART THERAPY 63 Session 7 Resilience is the Key 7.A. ICE BREAKER: “Ready, Aim, Fire” (10 min) Purpose: to improve resiliency, build group rapport, engage gross motor skills Materials: • Different sized, soft balls • Whiffle bat (4) Directions: • Set up the room so that the front or back half is free of chairs and/or tables • Place different sized balls around in a circle and 4 whiffle bats in the center • Divide group members into groups of 2 • “Today we are working on our resiliency skills. Imagine you all are on the battlefield; each team will have a turn in the ring of fire. Knights of the king, you are teamed with a partner, and you are the last two knights standing (in the middle). You are surrounded, but you two are the best knights left so you think you can take them. The commoners, you will toss the balls constantly for 2 minutes to try to defeat the king and his reign. If anyone is hit with a ball, you ‘lose’ that body part. For example, if you are hit in the arm, you must put your arm behind your back and play one handed for the remainder of the time. The last man standing wins for their team. Hazzah!” o Adaptations: If there are motor deficits, consider using a chair or having more than one person on a team. 7. B. PSYCHOEDUCATION: “Putting it All Together-Managing stress in various aspects of your life (physical, emotional, spiritual, social, environmental, and intellectual” (35 min) Materials: • Resilience Wheel (See Appendix Y) • Colored Pencils Topics of Discussion: • Resilience o Pass out the Resilience Wheel and follow the directions. o “Throughout group, we have been talking about the domains of resilience. Now let’s put it all together! First, you will be assessing your own performance on the resiliency domains. This is to help shed light on areas that you are doing well in, as well as areas you may want to improve. Using the colored pencils, shade in how well you think you are doing in each domain, on a scale of 1 meaning I need to improve, to 10, I am doing really well. Afterwards, you will choose your top 3 you would like to improve.” • Goal Setting o Discuss goal setting. Talk about the importance of creative small, observable, measurable goals. Highlight that small goals helps build success over time to tackle and reach the more challenging goals and decreases the likelihood of not following through.  Example: Goal-I want to run a marathon. You wouldn’t try to run all 26.2 miles the next day. You will need to map out and plan how you will get to 26.2 miles which actually involves a lot more than just running. This would include, training, adequate sleep, nutritious food choices, and GENDER AFFIRMING ART THERAPY 64 probably learning about marathon running through reading or research on the internet. o Flip to the back of your resilience wheel. Write down your top three domains you would like to improve. Create 3 small, observable, and measurable goals. You will notice that there are two check in areas. Once group is finished, you will be taking home your binder as a resource. It is up to you and whoever you choose as your accountability partner to check up on the progress of these goals. Remember, any progress, no matter how big or small, is progress. 7.C. DIRECTIVE: “Suit of Armor” (45 min) Purpose: to improve distress tolerance skills, build healthy coping alternatives, improve resiliency, gauge motivation to change Materials: • 2D Drawing materials o Colored pencils, crayons, markers, pencils o Oil pastels o Chalk pastels • Multimedia drawing pad Directions: • Sometimes life is really challenging and throws many daggers our way. Imagine you are a knight in the king’s army or a superhero who saves the world from crises. You are going to create an image of either super suit, suit of armor, and/or weaponry that keeps you safe during battle. Think about the material, function, and durability when creating this image. Processing Prompts: • Describe your armor. • Is it heavy or light? • What material is it made out of? • Is there any wear and tear? Can the blemishes be fixed? • Where do you keep your armor? • How often do you use it? • Does anyone know about your job? • Who or what keeps you safe? • Is there anything you wish you could add but that you aren’t able to? 7.D. ADDITIONAL: *Assess for food allergies and graduation snack preferences* GENDER AFFIRMING ART THERAPY 65 Session 8 So Long, Farewell 8.A. ICE BREAKER: “Name that Tune” (10 min) Purpose: to provide an interactive and fun way to engage in group closure Materials: • Names of goodbye songs cut typed and cut out onto strip of paper Directions: • “You will pick a strip of paper out of a bucket. On the strip of paper is a goodbye song. You will need to either hum, scat, or sing the melody of the tune WITHOUT saying any words. The group will need to guess the tune.” 8. B. PSYCHOEDUCATION: “Community & Support” (35 min) Materials: *Materials may differ depending on the city and state in which group is conducted. Art Therapists are responsible for familiarizing themselves with community resource. Resources should include suicide and/or mental health hotline information, community LGBTQIA+ organizations, and gender affirming health care providers* Topics of Discussion: • Provide community support resources. o Mental Health o Housing o Gender affirming health care providers • *For Columbus, OH resources (See Appendix Z) • Explore Trans Lifeline (https://translifeline.org), specifically the resources and hotline tabs. • Explore The Trevor Project site with group members, specifically the Get Help tab (https://www.thetrevorproject.org/get-help/) and the Crisis section (https://www.thetrevorproject.org/crisis-services/). Note that this resource is available to anyone no matter their location and there is a 24/7 hotline. 8.C. DIRECTIVE: “Pass it On” (30 min) Materials: • 2D Drawing Materials o Markers, pens, colored pencils • 2D Drawing Paper • List of positive character traits (one for each group member) Directions: • Set up tables and/or room so that group members are either in a circle or an arm. • “Since this is the last day of group, you will collectively be making each other an art piece for you all to take home with you. Take a sheet of paper and design or write your name in the center. Once everyone has completed this step, pass the paper to your right. When you get your peer’s paper, you will choose a word on the list provided that represents your perception of that group member. Create an image or design that reflects this word. When finished, you will all pass the paper to your right again. You will only have 5 minutes for each person, so whichever words comes first to mind, run with it! You GENDER AFFIRMING ART THERAPY 66 will complete an image for each group member and pass the paper to the right until you receive your name again.” Processing Prompts: • Look at your paper. Is there anything that surprises you? • How does it make you feel to see so many positive characteristics? • Do you see any commonalities or differences between the images? • Share one takeaway you have from this group. 8.D. ADDITIONAL: Measures & Snack (15) • Pass out Group measure (See Appendix D) • Pass out graduation snack. • Closing Group Remarks o Have each group member identify one take away from the group o Provide the opportunity for clients to exchange numbers/information GENDER AFFIRMING ART THERAPY 67 Section V: Discussion This paper explores the history of the transgender and gender diverse community and the role of mental health care in the field of art therapy. The literature review highlights the erasure, pathologization, and discrimination of the community, postulating affirming care considerations as well as terminology. It should be noted that terminology is continuously evolving. Consequently, art therapists and clinicians in the mental health field should ensure they are up to date with current considerations and terminology with this population. Additionally, the paper presents an 8-week closed art therapy program specifically working with transgender and gender diverse youth. The goals of the program focus on key mental health protective factors for gender diverse and transgender youth-such as resilience, improving identity, and psychoeducation about the transgender and gender diverse experience. Limitations There are several limitations to this program. The author identifies as a cisgender, heterosexual, and Caucasian clinician. Consequently, these identities hold privilege and in no way can the author fully understand the transgender and gender diverse experience. It was a personal journey to explore how to effectively work with this population through the field of art therapy while continuing practice through internship, with little to no prior knowledge about the nuances, intricacies, and history of this community. As of right now, this paper has not been consumed or explored with the transgender and gender diverse community. Additionally, there are several important factors to be added that are vital when working with specific age groups that are missing, such as consent, school issues, and familial support. Furthermore, representation of transgender and gender diverse individuals in the media and community were not explored. Conclusively, the program has not been implemented and thus there are no case GENDER AFFIRMING ART THERAPY 68 vignettes to support these approaches outside of the research the author has completed. Therefore, there are many directions for this paper and program post completion. Future Application First and foremost, it is the author’s intention to seek consultation with the transgender and gender diverse community in order to publish this paper to provide a concise and informative approach to art therapy for art therapists wishing to work with this population. It became apparent that there was a lack of research, approach, guidelines, and information when working with trans and gender diverse individuals in the field of art therapy, with one introductory book and 3 additional articles, mostly utilizing inappropriate language when referencing trans clients. Additionally, there is a lack of literature relation to the gender diverse community and the ASD community. Due to the strong relationship between individuals who identify as trans or gender diverse as well as having ASD, clinicians must continue exploring said relationship in order to prepare and/or address group member and client needs within session. This paper and program are merely steppingstones from which to build from in order to ensure art therapists are safely and effectively working with trans and gender diverse individuals. Credentialing and licensing agencies, such as AATA and ATCB should formally address and encourage the need for art therapists in the field to demonstrate competency in the community’s needs and current terminology. These are vital components to working with this population as treatment planning, goals, processing, and approaches in session are all impacted when gender expression and gender identity are a focal point of concern or exploration for the client and family. It the field’s duty to understand how to support this population in treatment and address GENDER AFFIRMING ART THERAPY their needs which play a key role in social justice advocacy, an important part of what it means to be an art therapist. 69 GENDER AFFIRMING ART THERAPY 70 References American Art Therapy Association. (2013, November 2). The AATA supports the affirmation and healthy development across the lifespan of individuals within LGBTQIA communities. https://arttherapy.org/news-affirmation-lgbtqia-communities/ American Art Therapy Association. (2017, November 2). The AATA supports the affirmation and healthy development across the lifespan of individuals within LGBTQIA communities. https://arttherapy.org/news-affirmation-lgbtqia-communities/ American Art Therapy Association. (n.d.). Definition: Organization. https://www.arttherapy.org/upload/2017_DefinitionofProfession.pdf American Psychiatric Association (1952). Diagnostic and statistical manual of mental disorders. American Psychiatric Press. American Psychiatric Association (1968). Diagnostic and statistical manual of mental disorders (2nd ed.). American Psychiatric Press. American Psychiatric Association (1980). Diagnostic and statistical manual of mental disorders (3rd ed., revised). American Psychiatric Press. American Psychiatric Association (1994). Diagnostic and statistical manual of mental disorders (4th ed.). American Psychiatric Press. American Psychiatric Association). (2000). Diagnostic and Statistical Manual of Mental disorders (4th ed., text revision). American Psychiatric Press. American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental disorders (5th ed.). American Psychiatric Press. American Psychiatric Association. (2015). Diagnostic and statistical manual of mental disorders (5th ed.). American Psychiatric Association Publishing. GENDER AFFIRMING ART THERAPY 71 Andrew, Scottie. (2021, January 27). Lawmakers in 14 states have proposed anti-LGBTQIA bills, many of which target trans youth. CNN. https://www.cnn.com/2021/01/27/us/anti-lgbtq-bills-2021-trnd/index.html Ansara, Y. G. & Hegarty, P. (2013). Misgendering in english language contexts: Applying noncisgenderist methods to feminist research. International Journal of Multiple Research Approaches, 7, 160-177. Doi: 10.5172/mra.2013.7.2.160. Austin, A. Transgender and Gender Diverse Children: Considerations for Affirmative Social Work Practice. Child and Adolescent Social Work Journal, 35, 73–84. https://doi.org/10.1007/s10560-017-0507-3 Austin, A., Craig, S. L., & Alessi, E. J. (2016). Affirmative cognitive behavior therapy with transgender and gender nonconforming adults. The Psychiatric clinics of North America, 1-16. Doi: 10.1016/j.psc.2016.10.003 Barbee, M. (2002). A visual-narrative approach to understanding transsexual identity. Art Therapy: Journal of the American Art Therapy Association, 19(2), 53-62. Doi: 10.1080/07421656.2002.10129339. Benjamin, H. (1966). The transsexual phenomenon: A scientific report on transsexualism and sex conversion in the human male and female. Julian. Bergin, A. E., & Niclas, M. A. (1996). Considerations for the treatment of children with gender identity disorder. Art Therapy: Journal of the American Art Therapy Association, 13, 270– 274. doi:10.1080/07421656.1996.10759236 Brill, S. & Kenney, L. (2016). The transgender teen: A handbook for parents and professionals supporting transgender and non0binary teens. Cleis Press. Cauldwell, D. O. (1949). Psychopathia transexualis. Sexology, 16, 274-280. GENDER AFFIRMING ART THERAPY 72 Centers for Disease Control and Prevention. (2011). Morbidity and mortality weekly report. https://owl.purdue.edu/owl/research_and_citation/apa_style/apa_formatting_and_style_g uide/reference_list_other_print_sources.html Centers for Disease Control and Prevention. (2016). Morbidity and mortality weekly report. https://www.cdc.gov/mmwr/volumes/65/ss/ss6506a1.htm Chang, S. C., Sing, A. A., & Dickey, L. M. (2018). A clinician’s guide to gender-affirming care: Working with transgender and gender nonconforming clients. Raincoast Books. Cohen, F. W. (1974). Art therapy in the diagnosis and treatment of a transsexual. American Journal of Art Therapy, 14, 3-11. Corey, G. (2016). Theory & practice of group counseling (9th ed.). CENGAGE Learning. Darke, K. & Scott-Miller, S. (2021). Art therapy with transgender and gender-expansive children and teenagers. Jessica Kingsley Publishers. Drescher, J. (2015). Queer diagnoses revisited: The past and future of homosexuality and gender diagnoses in DSM and ICD. International Review of Psychiatry, 27(5), 386395). DOI: 10.3109/09540261.2015.1053847 Editorial Research. (2021, February 2). LGBTQ rights milestones fast facts. CNN. https://www.cnn.com/2015/06/19/us/lgbt-rights-milestones-fast-facts/index.html Fleming, M. & Nathans, J. (1979). The use of art in understanding the central treatment issues in a female to male transsexual. Art Psychotherapy, 6, 25-35. CNN Politics. (2009, October 28). Obama signs hate crimes bill into law. http://www.cnn.com/2009/POLITICS/10/28/hate.crimes/ Darke, K. & Scott-Miller, S. (2021). Art therapy with transgender and gender-expansive children and teenagers. Jessica Kingsley Publishers. GENDER AFFIRMING ART THERAPY 73 Denato, M. P. (2012). The minority stress perspective. Psychology and AIDS Exchange. https://www.apa.org/pi/aids/resources/exchange/2012/04/minority-stress Drescher, J. (2015). Queer diagnoses revisited: The past and future of homosexuality and gender diagnoses in DSM and ICD International Review of Psychiatry, 27(5), 386395. Fitzsimons, T. (2018, October 15). LGBTQ history month: The early days of america’s aids crisis. NBC News. https://www.nbcnews.com/feature/nbc-out/lgbtq-history-monthearly-days-america-s-aids-crisis-n919701 Graham, T. C. (2019). Conversation therapy: A brief reflection on the history of the practice and contemporary regulatory efforts. Creighton Law Review, 52, 419-425. Haynes, S. (2019, May 28). The world health organization will stop classifying transgender people as having a ‘mental disorder.’ Time. https://time.com/5596845/world-healthorganization-transgender-identity/ History. (2017, June 28). Gay rights. https://www.history.com/topics/gay-rights/history-of-gay-rights Human Rights Campaign Foundation. (n.d.) Mental health and the lgbtq community. https://suicidepreventionlifeline.org/wpcontent/uploads/2017/07/LGBTQ_MentalHealt h_OnePager.pdf Khan, F. N. (2016, November 16). A history of transgender health care. Scientific American. https://blogs.scientificamerican.com/guest-blog/a-history-of-transgender-health-care/ Lev, A. (2018). Affirmative mental health care for transgender and gender diverse youth. (A. Janssen & S. Leibowtiz, Eds.). Springer International Publishing, AG. https://doi.org/10.1007/978-3-319-78307-9 GENDER AFFIRMING ART THERAPY 74 Leibowitz, S. (2018). Affirmative mental health care for transgender and gender diverse youth. (A. Janssen & S. Leibowtiz, Eds.). Springer International Publishing, AG. https://doi.org/10.1007/978-3-319-78307-9 Malchiodi, C. (2016). Why art therapy works: A recent study underscores the potential role of art therapy in recovery. Psychology Today. https://www.psychologytoday.com/us/blog/arts-and-health/201608/why-art-therapyworks 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, 674697. doi:10.1037/0033-2909.129.5.674 Milligan, L. (1996). A mother’s journey of healing: When a child changes gender. Art Therapy: Journal of the American Art Therapy Association, 13(4), 282-285. Doi: 10.1080/07421656.1996.10759238 Moon, B. (2007). The role of metaphor in art therapy: Theory, method, experience. Charles C. Thomas LTD. National Alliance on Mental Health Illness. (n.d.). LGBTQI. https://www.nami.org/Your-Journey/Identity-and-Cultural-Dimensions/LGBTQI Pelton-Sweet, L. M. & Sherry, A. (2008). Coming out through art: A review of art therapy with lgbt clients. Art Therapy: Journal of the American Art Therapy Association, 25(4), 170176. Perlata, E. (2013, June 26). Court overturns doma, sidesteps broad gay marriage ruling. NPR. GENDER AFFIRMING ART THERAPY 75 https://www.npr.org/sections/thetwo-way/2013/06/26/195857796/supreme-court-strikesdown-defense-of-marriage-act Piccirillo, E. (1996). In search of an accurate likeness; Art therapy with transgender persons living with AIDS. Art Therapy: Journal of the American Art Therapy Association 13, 3746. Doi: 10.1080/07421656.1996.10759191. Sage. (n.d.). Startling mental health statistics amongst lgbtq are a wake-up call. https://www.sageusa.org/news-posts/startling-mental-health-statistics-among-lgbtq-are-awake-up-call/ San Francisco State University. (2016). Family acceptance of lesbian, gay, bisexual and transgender youth protects against depression, substance abuse, suicide, study suggests. ScienceDaily. https://www.sciencedaily.com/releases/2010/12/101206093701.htm Schmidt, S. (2021, February 18). Equality act introduced in house to provide sweeping lgbtq protections. The Washington post. https://www.washingtonpost.com/dc-md-va/2021/02/18/equality-act-introduced/ Sherebrin, H. (1996). Gender dysphoria: The therapist’s dilemma: The client’s choice. Discovery and resolution through art therapy. Art Therapy: Journal of the American Art Therapy Association, 13, 47-53. Doi: 10.1080/07421656.1996.10759192. Stoller, R. J., Marmor, J., Bieber, I., Gold,d R., Socarides, C. W., Green, R. & Spitzer, R. L. (1973). A symposium: Should homosexuality be in the apa nomenclature? American Journal of Psychiatry, 130, 1207-1216. Stark, C. & Crofts, G. (2019). Advocacy-in-action: Case portrait of a helping professional pursuing positive social change for transgender and gender-expansive youth. Journal for Social Action in Counseling and Psychology, 11(2), 17-34. GENDER AFFIRMING ART THERAPY 76 https://doi.org/10.33043/JSACP.11.2.17-34 The Trevor Project. (2019). National survey on lgbtq youth mental health 2019. https://www.thetrevorproject.org/wp-content/uploads/2019/06/The-Trevor-ProjectNational-Survey-Results-2019.pdf The Trevor Project. (n.d.). Trans + gender identity. https://www.thetrevorproject.org/trvr_support_center/trans-gender-identity/ World Professional Association For Transgender Health. (2012). Standards of care for the health of transsexual, transgender, and gender-nonconforming people. https://www.wpath.org/media/cms/Documents/SOC%20v7/SOC%20V7_English2012.pdf ?_t=1613669341 World Health Organization. (1948). International classification of diseases and related health problems (6th ed.). World Health Organization. (1965). International classification of diseases and related health problems (8th ed.). World Health Organization. (1975). International classification of diseases and related health problems (9th ed.). World Health Organization. (1990). International classification of diseases and related health problems (10th ed.). World Health Organization. (2019). International classification of diseases and related health problems (11th ed.). Zappa, A. (2017). Beyond erasure: The ethics of art therapy research with trans and genderindependent people. Art therapy, 34(3), 120-134. https://doi.org/10.1080/07421656.2017.1343074 GENDER AFFIRMING ART THERAPY 77 Appendix A GENDER AFFIRMING ART THERAPY 78 Appendix B Community Bingo GENDER AFFIRMING ART THERAPY 79 Appendix C The Six Domains of Resilience These six domains have functions on their own, but they also influence each other. Just as strengths in some domains can compensate for weaker domains, so too can weakness in one drag down others. It is worthwhile for us to pursue personal development so that we are strong in all areas and effectively well-rounded. Let’s look at the six domains. Vision • The most important of the domains, Vision is about your sense of purpose, goals, and personal vision for yourself. The reason this is the most important domain is that all other domains are guided by what it is you want to achieve. Having clarity in this domain allows you to be decisive when facing tough choices, and to maintain perspective when facing challenges. Whether your goals relate to family, to work, or a side project, what’s important is being specific and clear. • Clarity keeps you focused. It’s easy to get distracted by unimportant details and events if you don't have anything specific you're working towards. After all, it’s not like you had anything else planned, so why not binge on the new season of House of Cards? Vision is about having clarity so that when things get tough, you know what’s important and what isn’t in order to stay focused and achieve your goals. • Congruence is the name of the game. Congruence means all your actions are working together across your larger vision of yourself and sense of purpose, through medium and short terms goals. When you don’t have clarity on these, it’s likely that some of your goals may conflict with each other, resulting in frustration as moving towards one goal moves you further from the other. Instead, if your actions are aligned, everything you do slowly moves you towards your ultimate goals, helping you achieve feats that others deemed impossible. Composure • It’s about regulating emotions. The fight-or-flight response of the brain loves to flare up when facing conflict or hearing about a sudden change at work. But being able to overcome that instinctive emotional response and maintain your composure often means being able to recognize hidden opportunities and solve problems in novel ways. This is because becoming emotional prevents you from properly accessing your ability to think critically. • It’s also the little things. Composure is not just the big crises that we face, but also the little everyday things. Getting emotional in a traffic jam is never useful, so why bother getting worked up? Maintaining composure means keeping calm so you can save your energy for what is important. GENDER AFFIRMING ART THERAPY 80 • Interpretation bias is important. Your boss walks up to you and says, “I need to talk to you. Come see me later”. Do you panic? Do you worry about getting into trouble for something or getting fired? The statement from your boss in this example is actually neutral with no direct implied negativity. It could just as easily be good news! Research shows that a natural inclination to negatively interpret ambiguous situations makes people six times more likely to show symptoms of depression, while a positive interpretation bias results in higher resilience. • You also need to be proactive. Composure is not just about being able to return to a state of poise, but also about considering your own beliefs and expectations that produce emotions in the first place. For example, if you expect that nothing will ever go wrong with your project, then you’re likely in for a big shock. Compare that with a healthier belief that, most likely, something will go wrong, and when it does, you’ll manage it. It’s easy – just expect that everything will be harder than you expect! Reasoning • Creativity and innovative problem solving is incredibly useful when facing challenges along the way. This is what the Reasoning domain is all about. This domain needs Composure for you to keep your cool, as well as Vision so you know what goals to direct your actions toward. • Anticipate and plan. Like Composure, it’s not just about applying critical thinking during a crisis, but also about taking action ahead of time to prevent things from going wrong in the first place. In fact, it’s mostly about proactive action. This is like going to the dentist regularly so you won’t need a root canal later. Think proactively through how things may go wrong and take action ahead of time to prevent or minimise impact, and think through how you’ll deal with different scenarios. • Be resourceful. Having the right information, tools, techniques and people available to you will help you solve problems more effectively and find more efficient ways to reach your goals. Resourcefulness is a skill we need to actively build, and the more resourceful we are, the easier it becomes to make unusual connections and find innovative ways forward. • See opportunity in change. A high Reasoning ability means that a changing environment is welcome since it always brings hidden opportunities. By maintaining your composure and knowing what you want to achieve, change is no longer a threat and you can look for things that others might have missed, helping you to succeed. Tenacity • Persistence is the key. Einstein pointed out the importance of persistence for success when he said that “It’s not that I’m so smart, it’s just that I stay with problems longer”. In a globalized world, success is no longer a given. We need to be willing to work hard GENDER AFFIRMING ART THERAPY 81 and smart and stay with a problem if we hope to achieve something, especially if you want to achieve something that no one else has. • Learn from mistakes. Rarely will we do things right the first time. And even when doing something we know well, eventually we will make mistakes. At home, with friends, at work. Mistakes creep in everywhere, so what is important is how we react to mistakes. Admonishing ourselves doesn’t help. Instead, it’s important to be able to objectively look at our mistakes, find lessons in them, and not define ourselves by them. The past is there to learn from, not to dwell on. • Don’t be naïve, have realistic optimism. Research shows that people who are overly optimistic about succeeding are less likely to, since they tend to give up at the first sign of trouble. What is more useful for success is to have a sense of ‘realistic optimism’, meaning that you are hopeful about your ability to succeed, but you realize that the road will be tough and full of challenges. This realization combined with the willingness to be persistent is what ultimately leads to success for individuals, teams and organizations. Collaboration • We are social beings. The brain has a deep fundamental need for connection with others to be able to thrive. The brain has dedicated neural structures to recognize facial expressions, while mirror neurons fire within the brain to help us empathize with others. We are, after all, in this together, so what we do and focus on is not just for us, but to help our communities together and improve our world. This connection is what the Collaboration domain is about. • Support and be supported. In a complex world, few of us can achieve anything meaningful alone, so it’s crucial for us to build support networks so we can both have a safety net and also be that safety net for others. Interestingly, research shows that when it comes to peace of mind, it’s not actual available support that matters, but instead it is the perception of available support that’s important. So even if you have 100 people ready to support you, if you don’t realize this, you will not feel supported. Keep this in mind for others as well, and show the people you care for that you are there to support them whenever they need you. • Get the context right. A key part of Collaboration is understanding the context of your interaction with people. Having a meeting with people at work and spending time with friends on the weekend are two very different contexts. For example, at work it’s more important to focus on facts than on emotion, keep things professional and don’t take anything personally. At home, it’s not always about the facts, but very important to address emotions as it’s a vital part of maintaining healthy relationships. Scoring high in Collaboration means being able to know what behavior is best in different contexts so you can keep things constructive and build positive relationships. GENDER AFFIRMING ART THERAPY Health 82 • The foundational domain. Good health means looking after your body through what you eat, doing exercise, and getting quality sleep. A healthy body provides a strong foundation for your own resilience so you can focus on your sense of purpose and goals. Good health is not the ultimate goal itself, but instead is an enabler to achieve your larger personal vision. • Healthy nutrition. It’s not just about keeping lean, as nutrition also affects your brain health and mental performance. Regularly eating foods with a high combination of fats and sugars (like chocolate, ice cream, cookies, baked goods, burgers…) actually reduces the chemical in the brain that produces more brain cells. This makes the brain less plastic and reduces your mental adaptability. • Quality sleep. Lack of sleep results in more mistakes, reduced attention span, and a decreased ability to deal with stress. It also increases cortisol, the brain’s stress hormone. The affects add up over time, compounding the toll on your body, brain, and performance. Sleep makes a big difference, but it’s not just about quantity, it’s about getting enough quality sleep. • Regular exercise. Also not just about being fit, regular exercise is proven to increase mental performance and increasing your ability to learn. It also protects against neurodegenerative diseases in the long term. So even if you are happy with your body, exercise is still crucial! What’s great about these domains is we absolutely have the capacity to build and improve every domain, and therefore develop our own resilience. Resilience is a life-long and ongoing journey for us and our effort here improves quality of life and directly contributes to the achievement of personal and organizational goals. GENDER AFFIRMING ART THERAPY 83 Appendix D GENDER AFFIRMING ART THERAPY 84 Appendix E GENDER AFFIRMING ART THERAPY Paired Interviews Instructions: Sample questions for interviews are below. Feel free to ask other questions, as these are just suggestions. What do you like to do for fun? What do you plan to do after High School? What is one strength/talent that you have that you are proud of? Where are your favorite/fun places to visit in the community? What is your favorite food? What kind of music do you like? What is your best friend’s best quality What is something you are glad you did, but would never do again? What is one thing you wish you were really good at? What is your favorite time of year? Who is a famous person you would like to meet? What animals do you like? What is your favorite movie of all time? What is the best book you have ever read? What was your favorite childhood toy? What is your wildest career fantasy? What is your favorite holiday? 85 GENDER AFFIRMING ART THERAPY 86 Appendix F Emotion Scaling GENDER AFFIRMING ART THERAPY 87 Appendix G GENDER AFFIRMING ART THERAPY 88 Coping Tools Appendix H GENDER AFFIRMING ART THERAPY 89 Coping Toolbox Appendix I GENDER AFFIRMING ART THERAPY 90 GENDER AFFIRMING ART THERAPY 91 GENDER AFFIRMING ART THERAPY 92 Appendix J GENDER AFFIRMING ART THERAPY 93 GENDER AFFIRMING ART THERAPY 94 GENDER AFFIRMING ART THERAPY 95 GENDER AFFIRMING ART THERAPY 96 GENDER AFFIRMING ART THERAPY 97 GENDER AFFIRMING ART THERAPY 98 GENDER AFFIRMING ART THERAPY 99 GENDER AFFIRMING ART THERAPY 100 Appendix K GENDER AFFIRMING ART THERAPY 101 Appendix L Try It Out!: my gender To explore your inner thoughts and feelings about gender, get in a safe, quiet space so you can answer the following questions as honestly as possible. What are some of your earliest memories related to gender? (For example: I remember my dad saying, “Are you sure you don’t want a blue balloon? Blue is for boys.” Or, I remember wanting to be in Boy Scouts like my brother, but my parents said I couldn’t because I was a girl.) _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ __________________ Were you ever told you looked or acted like a boy? Like a girl? How did you feel when this happened? _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ __________________ GENDER AFFIRMING ART THERAPY 102 How would it or does it feel when people see you as a boy or man? (A note for this question and the next two: Sometimes when you imagine these scenarios, the first thing you feel is fear. Fear can overshadow other emotions. So if you feel fear, write that down, but then put down what other emotions you would feel after that. It may help to think of this happening in a special situation where there would be no possible danger or rejection.) beginning the journey _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ __________________ How would it or does it feel when people see you as a girl or woman? _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ __________________ How would it or does it feel when people see you as a gender other than girl/ woman or boy/man (for example, as androgynous or Two-Spirit)? _____________________________________________________________________________________________ _____________________________________________________________________________________________ GENDER AFFIRMING ART THERAPY 103 _____________________________________________________________________________________________ _____________________________________________________________________________________________ __________________ 21 the gender quest workbook Who are your gender role models? In other words, if you could be like anyone in terms of gender, who would you be like? _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ __________________ Fold a piece of paper in half, like a book. Draw on the cover of this book how you think other people see your gender. Now open the book. Draw how you see your gender, or how you would like the world to see your gender. If they are different, draw both on different sides of the inside of your book. How do you feel when you look at each version of yourself? _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ __________________ GENDER AFFIRMING ART THERAPY 104 Read the following examples. Underline parts of people’s experiences that feel “right on” to you. Cross out parts that feel different from your experience. Some parts won’t have an underline or a cross; they will just be neutral or unsure, and that is fine. My whole life I felt like something just wasn’t right. Sometimes I would look in the mirror and feel like I was looking at someone else. Like it wasn’t me. The person I saw in the mirror and the person I felt I was were not the same. I love to be surprising: I make sure that people know that even though they see me as a girl, I love sports. Or, if they think I’m a “tomboy,” that I also have a huge number of dresses. 22 As a child it never really crossed my mind that I was transgender. I seemed to like all the same things that the other boys liked. I liked sports and I liked girls. It was not until high school that I started to think that my experience was different. It is hard to describe how I felt or why I felt that way but I just did not feel like a guy. When I say that I am a woman it feels right. I feel like I have always been a woman and not much has really changed. I still like sports and I still like girls. I’ve spent a lot of time trying to prove to people that I’m not gay. As hard as I try, though, people always seem to notice that I’m more feminine than other guys. My parents criticize me a lot for this. I love being a girl and I always have! I always hated dresses. I hated dolls. I hated Barbies. I preferred playing with all my brother’s toys and never touched my own. As a kid my mom would always say I was a tomboy and tell my dad that I would outgrow it. I never did. There never came a time when I wanted to wear a dress or paint my nails. I never really cared or thought about whether I was a girl or a boy until I was around twelve years old. My body started to change and I did not like it. It felt wrong, like something was happening that I could not control. Something I did not want. I never really felt like a boy, but I never really felt like a girl either. I just wish I could move somewhere that gender doesn’t exist and be me—not a boy or a girl. Kids at school always make fun of me for acting “like a girl.” The truth is, I do kind of feel more like a girl than a boy. But it’s hard to say that. GENDER AFFIRMING ART THERAPY 105 I’m a total boy and that’s just me. But I also really like that I was raised a girl when I was younger. I think it made me better able to understand different perspectives. Now combine all the parts of the above experiences that felt “right on” to you and write them below: beginning the journey _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ __________________ 23 the gender quest workbook Does this represent your experience? What is missing? _____________________________________________________________________________________________ _____________________________________________________________________________________________ ________________________________________________ Appendix M GENDER AFFIRMING ART THERAPY 106 GENDER AFFIRMING ART THERAPY 107 Appendix N GENDER AFFIRMING ART THERAPY 108 Appendix O GENDER AFFIRMING ART THERAPY 109 Appendix P GENDER AFFIRMING ART THERAPY 110 GENDER AFFIRMING ART THERAPY 111 Appendix Q GENDER AFFIRMING ART THERAPY 112 GENDER AFFIRMING ART THERAPY 113 Appendix R GENDER AFFIRMING ART THERAPY 114 Appendix S GENDER AFFIRMING ART THERAPY 115 Appendix T GENDER AFFIRMING ART THERAPY 116 Appendix U GENDER AFFIRMING ART THERAPY 117 Appendix V GENDER AFFIRMING ART THERAPY 118 Appendix W GENDER AFFIRMING ART THERAPY 119 Appendix X GENDER AFFIRMING ART THERAPY 120 GENDER AFFIRMING ART THERAPY 121 GENDER AFFIRMING ART THERAPY 122 GENDER AFFIRMING ART THERAPY Appendix Y Resilience Wheel 123 GENDER AFFIRMING ART THERAPY Adapted from 8 Dimensions of Wellness Assessment. Marshall Wellness Center. (2021, June, 14). https://www.marshall.edu/wellness/files/Wellness-Self-Assessment-fillable.pdf 124 GENDER AFFIRMING ART THERAPY 125 Appendix Z Resources for Columbus, Ohio Please visit https://www.kycohio.org/resources.html for a move extensive list HOTLINES • Franklin County Youth Psychiatric Crisis Line o Telephone: (614)-722-1800 *17 and Younger • Netcare Access Crisis Line o Telephone: (614)-276-2273 *Live Chat Available AGENCIES • THRIVE Gender Program-Nationwide Children’s Hospital o Address: 700 Children’s Drive Columbus, OH 43205-Main Campus, 3rd Floor o Telephone: (614)-722-5765 o Website: https://www.nationwidechildrens.org/specialties/thrive-program o Services: mental health care, gender affirming medical care, psychiatry • Star House o Website: https://www.starhouse.us o Services: housing, transitional employment, mentor groups • Netcare Access o Address: 199 S. Central Avenue Columbus, OH 43223 o Telephone: (614)-276-2273 o Website: https://www.netcareaccess.org o Services: crisis stabilization & assessment, residential programming, public intoxication transportation, developmental disability services • Huckleberry House o Address: 1421 Hamlet Street Columbus, OH 43201 o Telephone: (614)-294-8097 o Website: https://www.huckhouse.org o Services: housing, counseling, professional development • ADAMH o Address: o Telephone: o Website: o Services: • Kaleidoscope Youth Center o Address: 603 East Town Street Columbus, OH 43215 o Telephone: (614)-294-5437 o Website: https://www.kycohio.org o Services: youth programs, education and training, housing, advocacy, extensive resource list (food, housing, internet access) Adapted from Resources. Kaleidoscope Youth Center. (n.d.). https://www.kycohio.org/resources.html