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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

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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

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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

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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.

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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

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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

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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

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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).

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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.

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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.

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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

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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.

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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

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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

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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),

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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

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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

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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

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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

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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

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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

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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.’

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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,

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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

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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

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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

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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

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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.

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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.

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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

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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

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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

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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,

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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

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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.

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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,

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“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

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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.

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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.

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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-

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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

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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

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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.

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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

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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.

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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

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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.

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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

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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

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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

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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

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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)

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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

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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)

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• 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!

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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)

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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)

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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

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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?

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5.D. ADDITIONAL: None

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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

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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

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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

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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*

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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

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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

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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

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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

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their needs which play a key role in social justice advocacy, an important part of what it means
to be an art therapist.

69

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Appendix A

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Appendix B

Community Bingo

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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.

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•

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

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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.

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•

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.

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Appendix D

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Appendix E

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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?

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Appendix F
Emotion Scaling

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Appendix G

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Coping Tools

Appendix H

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Coping Toolbox

Appendix I

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Appendix J

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Appendix K

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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?
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
__________________

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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)?
_____________________________________________________________________________________________
_____________________________________________________________________________________________

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_____________________________________________________________________________________________
_____________________________________________________________________________________________
__________________
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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?
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
__________________

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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.

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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

_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
__________________
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the gender quest workbook

Does this represent your experience? What is missing?
_____________________________________________________________________________________________
_____________________________________________________________________________________________
________________________________________________

Appendix M

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Appendix N

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Appendix O

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Appendix P

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Appendix Q

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Appendix R

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Appendix S

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Appendix T

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Appendix U

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Appendix V

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Appendix W

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Appendix X

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Resilience Wheel

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Adapted from 8 Dimensions of Wellness Assessment. Marshall Wellness Center. (2021, June, 14).
https://www.marshall.edu/wellness/files/Wellness-Self-Assessment-fillable.pdf

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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