DISCRIMINATION AND RESILIENCE AT THE MARGINS OF GENDER DIVERSITY by Laura Imayoshi Bachelor of Arts, University of British Columbia, 1997 Masters of Divinity, Starr King School for the Ministry, 2004 MAJOR PAPER SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SOCIAL WORK in the Department of Social Work © Laura Imayoshi 2022 UNIVERSITY OF THE FRASER VALLEY Spring 2022 All rights reserved. This work may not be reproduced in whole or in part, by photocopy or other means, without permission of the author. ii Approval Page Name: Degree: Title: Laura Imayoshi Master of Social Work Discrimination and Resilience at the Margins of Gender Diversity Examining Committee: Dr. Leah Douglas Graduate Program Committee Chair and Senior Supervisor Associate Professor, School of Social Work & Human Services Dr. Evan Taylor Second Reader Assistant Professor, School of Social Work & Human Services Date Defended/Approved: April 2022 iii Abstract Gender diverse people commonly have experiences of trauma and stories of resilience. This paper presents a thematic summary of recent academic journal articles to better understand how people experience gender diversity, discrimination, and resilience. The literature is reviewed with the intention of discovering best practices for social workers who work with gender diverse adults particularly in counselling or community settings, including people with non-binary identities. Using anti-oppressive theory, minority stress theory, and red intersectionality, various multiple marginalities are explored. These various identities include the intersections of gender diversity with race, culture, poverty, neurodivergence, older adults, and religion. Non-binary identities are also considered. Health impacts of discrimination against gender diverse people are discussed, including the important role of inclusive community. Implications for social work practice and policy are explored. Key words: gender diversity, non-binary, intersectionality, discrimination, resilience iv Table of Contents Approval Page ................................................................................................................................. ii Abstract .......................................................................................................................................... iii Table of Contents ........................................................................................................................... iv Introduction ..................................................................................................................................... 1 Research questions ................................................................................................................ 2 Theory.................................................................................................................................... 2 Anti-Oppressive Practice ............................................................................................. 3 Red Intersectionality .................................................................................................... 4 Minority stress theory .................................................................................................. 5 Significance ........................................................................................................................... 6 Positionality ........................................................................................................................... 7 Methods........................................................................................................................................... 7 Literature Review............................................................................................................................ 9 Language ............................................................................................................................... 9 Pronoun use ................................................................................................................ 10 Two-spirit ................................................................................................................... 11 Non-binary ................................................................................................................. 12 Gender dysphoria ....................................................................................................... 13 Queering ..................................................................................................................... 13 Health disparities ................................................................................................................. 14 The effects of discrimination and trauma .................................................................. 15 Social implications .............................................................................................................. 17 v Unsafe in queer spaces ............................................................................................... 19 Housing and shelter .................................................................................................... 20 Identity ................................................................................................................................. 21 Poverty ....................................................................................................................... 22 Non-binary identities.................................................................................................. 23 Race ............................................................................................................................ 23 Culture ........................................................................................................................ 25 Neurodivergence ........................................................................................................ 25 Religion/ spirituality .................................................................................................. 27 Older adults ................................................................................................................ 28 Resilience ............................................................................................................................ 29 Protective factors........................................................................................................ 29 Affirmative counselling to support resilience ............................................................ 31 Discussion ..................................................................................................................................... 35 Implications for Social Work Practice ................................................................................ 35 Micro .......................................................................................................................... 36 Mezzo ......................................................................................................................... 38 Macro ......................................................................................................................... 40 Gaps in literature ........................................................................................................................... 41 Conclusion .................................................................................................................................... 44 References ..................................................................................................................................... 46 1 Introduction Although gender diverse people face discrimination and stigma on a regular basis, they deserve to live safely and well. Gender diverse people commonly face unjust treatment in public settings such as when seeking housing (Lyons et al., 2016), or “economic opportunities” (Lyons et al., 2016, p. 373) for example. Gender diverse people have poorer access to healthcare (Lykens et al., 2018; Lyons et al., 2016) and report poorer mental health (Meyer, 2003; Rutherford et al., 2021). Despite these common occurrences, gender diverse people have shown resilience in a variety of ways, including providing support for other gender diverse people (Beischel et al., 2021; Cosgrove, 2021). As well, community connection and personal relationships often provide support and healing. However, in order to provide care that is safe and supportive, social workers need to be aware of the challenges and stigma gender diverse people face, as well as the strengths of gender diverse people and their communities. People with experiences of gender diversity living in a society that understands gender in a binary way, face traumas such as discrimination, microaggressions, increased risk of violence, and lack of safety (Rutherford et al., 2021). This paper will explore how resiliency is a tool available to gender diverse people as they struggle against discrimination. A few key terms will be used throughout this paper. The literature used a wide variety of terms to describe gender identities other than those assigned at birth, and also for individuals who are sexually and/or gender diverse (SGD). This paper will use the term ‘gender diverse’ to talk about people with a variety of gender identities that are distinct from those assigned at birth. In addition, this paper will use the commonly accepted term SGD (Stone et al., 2020a) as an umbrella term to mean all people who identify with gender or sexual diversity. Finally, non- 2 binary will be the term used to describe all people whose experience of gender falls outside of the binary notions of male and female. The paper will examine social work’s roles in serving gender diverse individuals and communities. More specifically, this paper will explore how discrimination effects gender diverse people to learn how social workers can support resilience of gender diverse people and resistance to oppressive policy, structures, and society in general. Consequently, the research questions guiding this work explore gender diversity, and how to support resilience from a social work perspective. Research questions The research questions are: How do social workers incorporate learnings on gender diverse experiences as they relate to discrimination and resilience? How can we “queer” and decolonize social work practice to best support gender diverse people with multiple marginalities? How can social work support gender diverse people to be resilient in ways that reflect diverse experiences? Theory The research for this paper was completed using three theories to inform the work. The primary theory was anti-oppressive practice. As well, red intersectionality (which will be explained below), and minority stress theory helped with interpreting the research and articulating the implications for social work practice. The Canadian Association of Social Workers’ Code of Ethics calls to “advocate for fair and equitable access to resources to meet basic human needs” (CASW, 2005, p. 5), and these three theories were chosen as a way to critically examine gender diversity in light of fair and equitable access to resources. 3 Anti-Oppressive Practice The main theory that will guide this paper is anti-oppressive practice, which is concerned with power and how it works. According to Baines (2017), anti-oppressive practice “attempts to analyze how power works to oppress and marginalize people as well as how power can be used to liberate and empower them across a wide range of social settings, relations, environments and systems” (p. 31). Anti-oppressive practice calls the social worker to examine their own power and privilege, and to commit to ongoing learning and openness to better understand how power and authority work in social settings. Anti-oppressive practice further requires us to consider marginalized voices and marginalized experiences to work towards equity and a just society. Employing anti-oppressive practice, we are compelled to amplify and centre marginalized people and their needs. Accordingly, anti-oppressive practice centres social justice work as primary to social work. Although social workers may practice on the micro level with individuals, there is an understanding of how oppression is ongoing and systemic through colonization and gendered cultural norms. Clark (2016) and Baines (2017) discussed trauma and poor health outcomes within the context of oppression. Baines (2017) wrote, “anti-oppressive practitioners argue that what we call ‘clinical depression’ cannot be fully addressed separate from poverty, sexism, racism, gender, sexual orientation, social alienation and other oppressive forces experienced by many people bearing this label” (p. 21). Rather than accepting the status quo, anti-oppressive practice calls us to leverage our privilege and authority to support justice efforts. 4 Red Intersectionality As this paper intends to look to the margins of gender diverse experience to better understand resilience, Indigenous perspectives need to be considered. Clark (2016) considered colonization in what she called “red intersectionality”. Although Clark’s work focused on Indigenous girls, this author believes that her theory translates well to working with Indigenous gender diverse and Two-Spirit people, as both demographics are at increased risk of violence and stigma. Clark argued for the need to understand both the resistance and resilience of the storyteller. Clark (2016) criticized trauma-informed practice when it personalizes the experiences of trauma; in this way trauma-informed practice becomes a tool of ongoing colonization. She wrote, “a red intersectional analysis to trauma and girls requires us to consider how the so-called trauma industry has continued a colonial legacy of labeling and pathologizing Indigenous girls that manages their behavior through criminalization, medication, and talk therapy programs” (2016, para. 12). For red intersectionality, stories of violence were told alongside stories of resistance to systems of sexism, colonialism, and racism. Clark called for intentional witnessing of violence as well as resistance that cannot be separated from larger systemic violence and harm within Canadian society. Thus, to translate Clark’s work to the current context, this author asserts that social work needs to amplify the stories of resilience as well as of the everyday violence that gender diverse Indigenous and two-spirit people face. This author seeks to find out whose voices are being heard and whose are not. This paper will consider who is defining the narrative and needs of the gender diverse people and whether researchers are ensuring that people with multiple marginalities are contributing to the conversation. Ultimately, this author wants to use creativity and curiosity to remain engaged in changing language, power, and knowledge itself. 5 Minority stress theory In addition to intentional use of language as a means of social work’s ethical imperative to respect “inherent dignity and worth of persons” (CASW, 2005, p. 4), minority stress theory offers a way to understand and normalize gender diverse people’s experiences of discrimination. In 2003, Meyer wrote a foundational text proposing minority stress theory and how it affected lesbian, gay, and bisexual people. Several current authors (Beischel et al., 2021; Bowling et al., 2019; Coleman-Smith et al., 2020; Galupo et al., 2020; Hendricks & Testa, 2012; Matsuno, 2019; Reisner et al., 2016; Stone et al., 2020a) still refer to Meyer’s theory and have expanded it to better understand gender diverse people and negative health (and mental health) outcomes. Meyer (2003) articulated the ideas of distal stress (such as systemic or generalized discrimination) versus proximal stress (such as concealing one’s identity). Meyer spoke about the toll that discrimination and stigma take on mental health, arguing that people with marginalized sexual identities experienced unique stressors. However, Meyer (2003) recognized minority stress could also be a source of resilience as people found communities and social networks of solidarity with people who shared their identity. Hendricks and Testa (2012) built on Meyer’s explanation of the minority stress theory. They used a psychological lens to consider how minority stress theory applies to gender diverse adults. The authors considered high rates of suicidality for gender diverse people and called for psychologists working with gender diverse people to regularly assess and treat for the effects of trauma, resilience, and suicidality. Meyer (2003) and Hendricks and Testa (2012) noted how people with experiences of minority stress can have symptoms of trauma, such as hypervigilance, which could develop as a survival response to feeling chronically unsafe. Hendricks and Testa (2012) highlighted the importance of social connections for gender diverse 6 people who may be prone to feelings of loneliness and disconnection due to transphobia and discrimination. Further, gender diverse people may experience feelings of burdensomeness, particularly in response to job loss or homelessness that may be related to gender diversity. Finally, Hendricks and Testa (2012) pointed out the need for affirming psychological care as many need a psychologist’s support to access gender affirming care. Matsuno (2019) added the idea of how distal or external experiences of societal discrimination, or erasure, reinforced and exacerbated proximal stressors such as how a nonbinary person understands belonging or their own identity. Intersectionality exacerbates experiences of minority stress. Coleman-Smith et al. (2020) researched gender diverse people with diagnoses of autism and found that both gender diversity and autism created situations of minority stress. People who hold both identities faced harassment and discrimination for both, which served as an increased risk factor for mental health problems including anxiety, depression, and suicidal ideation (Coleman-Smith et al., 2020). Significance This author found relatively few resources about non-binary experiences, particularly non-binary people who identify as having multiple marginalized identities. Cosgrove (2021) notes a “dearth of research” (para. 2) regarding non-binary identities specifically. As well, there are few academic resources on gender diversity that suggest social work implications. Rutherford et al. (2021) write, “existing evidence indicates that there are significant socioeconomic and healthcare disparities between trans and non-binary people and their cisgender peers” (para. 3). Acknowledging such disparities calls for a social work response according to our Code of Ethics (CASW, 2005) which states, “Social workers advocate for fair 7 and equitable access to public services and benefits” (p. 5). Thus, this writer will analyze what is currently available and translate the work to provide research- based tools to apply to the practice of social work. Given the higher rates of experiences of violence and discrimination, and health inequity as experienced by gender diverse people, social work can play a vital role in improving health access and support resilience for gender diverse people. Positionality I am a White, able-bodied, person. As such, I am privileged to be able to offer this paper as partial completion of my Masters of Social Work degree. I immigrated to Canada as a child. Experiences in the last year of my life have made me reconsider my gender identity and what it means. I have experience working with sexually and gender diverse communities, and also working with people with a variety of intersectionalities. With an academic background in religion and theology, I am particularly interested in how religion and spirituality intersect with gender diversity. Methods This paper presents a thematic review of academic sources on gender diversity, discrimination, and resilience. Specific search terms used to find the literature included combinations of the following words: transgender, non-binary, Two-Spirit, intersectionality, social work, resilience, discrimination, and trauma. The articles chosen are predominantly from the last five years (2016 to 2021), with the exception of those related to minority stress theory (Hendricks & Testa, 2012; Meyer, 2003), a foundational theory for study in this area, and the Canadian Association of Social Work’s Code of Ethics (2005). Where possible, Canadian research was chosen. However, few Canadian articles on non-binary and intersectional gender diverse experiences were found, so articles from other countries (US, UK, Ireland, Australia) 8 were also chosen. Three articles (Galupo et al., 2020; Pulice-Farrow et al., 2017; Snooks & McLaren, 2021) were chosen that were global in focus, but predominantly US based. The literature chosen came from English speaking countries because of the importance of language for understanding gender diversity. Using Ebsco (through the University of the Fraser Valley library) and Google Scholar, all articles found were available in digital format. Research articles are from the fields of social work, social services, psychology, public health, counselling, and feminism. The 37 texts chosen were academic, peer-reviewed, and included 34 journal articles, two organizational publications (American Psychiatric Association, 2013; Canadian Association of Social Workers, 2005), and one book (Baines, 2017). Twenty-one texts were studies conducted with participants. These research studies used a mix of quantitative and qualitative surveys and interviews. Methods for studies included participatory action, photovoice, semi-structured interviews, and online and in-person surveys. The 13 additional journal articles included in the literature review that were not studies were a variety of different forms including explanations of theories (Clark, 2016; Hendricks & Testa, 2012; Meyer, 2003; Robinson, 2017; Robinson, 2019; Singh, 2016), frameworks for practice (Knutson & Koch, 2021; Rider et al., 2019), professional recommendations (Matsuno, 2019; Porter et al., 2016), reflections on working with one particular client (Cain & Velasco, 2021; Lord, 2020), and a literature review (Kia et al., 2021). In searching for articles to contribute to a conversation about social work with gender diverse people, this author made decisions about what to include or exclude. Articles that focused on youth or childhood experiences, incarcerated people, or reproductive justice were excluded. The articles chosen focus broadly on the social determinants of health as they relate to 9 gender diverse adults. This area was chosen as it is both relevant for social workers, and more closely related to the practice experience of this author. In beginning to gather articles, this author noticed that non-binary experiences were less well researched than binary transgender experiences. Consequently, this paper will focus on nonbinary experiences and intersectional voices of gender diverse people. Literature Review The recent related literature that can inform social workers on best practices for working with gender diverse people around discrimination and resilience revealed six common themes, as well as several sub-themes. The first theme that will be explored is language and will include consideration of pronouns, relevant terms, and how language can be used intentionally to connect and create safety. The next theme to be discussed is health disparities, including discrimination and its effects. The social implications of gender diversity will then be explored, including lack of safety in queer spaces and social services. Identity will be considered as it was a major theme with many specific multiple marginalities, including poverty, non-binary people, race, culture, neurodivergence, religion or spirituality, and older adults. The theme of resilience will be the final theme explored including protective factors as well as affirmative counselling to support resilience. Language Language is a way to build safety and rapport when working with people. As gender diverse people use language in a variety of ways, social workers need to use the language that best fits for the individual or situation (Cosgrove, 2021; Matsuno, 2019). Language that does not include people can create stress and an emotional toll for gender diverse people (Galupo et al., 10 2020). Social workers need to employ language that people use to refer to themselves, understanding that for some people, gender and language are fluid over time. Language is an important way to begin a conversation about gender, as the chosen language needs to be intentional. In this literature review, different authors used many different terms to describe people’s gender, and study participants further expanded this list. However, in order to write about people with a variety of gender identities, this paper uses ‘gender diverse’ with a recognition that not all people with a gender other than the one they were assigned at birth might identify with this term. In addition, the term sexually and/or gender diverse (SGD) is used to encompass people who identity with gender or sexual diversity. The literature uses a great variety of other terms (such as nonconforming, agender, genderqueer, and gender fluid). Although each of these terms has meaning on its own, for ease of understanding, this paper intends to include all of these in the term gender diverse. Other terms relevant to the discussion will be explained below, along with insights from the literature regarding pronoun use. Pronoun use Social workers should practice intentional use of pronouns for themselves and all people as a means of creating safety for gender diverse people (Cosgrove, 2021). Anti-oppressive social work incorporates self-reflection, and in this context, reflection on our own gender and how we came to understand gender. Further, people may choose to change their pronoun use at times to better reflect their gender at that time, or because of safety issues (Matsuno, 2019). Thus, checking in regularly with people by stating your own pronouns and asking others for theirs, is an ongoing practice of inclusivity and solidarity with gender diverse people. 11 Two-spirit In considering discrimination, Indigenous perspectives offer insight and add important knowledge and history to the understanding of gender diversity. Two-spirit identity is still an emerging area of scholarship. Robinson has published two articles (Robinson, 2017; Robinson, 2019) that contribute valuable knowledge of Indigenous understanding of gender and sexuality. Robinson (2017) wrote, two-spirit, a translation of the Ojibwe term niizh manidoowag, is an identity that emerged in 1990 to describe third or fourth gender people in Indigenous cultures (e.g., First Nations, Métis, Inuit, American Indian, and Alaskan Native) across what is now called North America. (p. 9) Robinson (2017) discussed the term two-spirit and the multiplicity of meanings it now holds for Indigenous people and Indigenous communities. In traditional, pre-contact Indigenous cultures there were distinct roles and understandings for people of all genders and sexualities. Two-spirit could refer to gender, or sexuality, or both, and perhaps this vagueness is more inclusive. Robinson quoted one study participant as saying, “I like the ambiguity that it has, so that you can say that you're two-spirit and it doesn't hold you as one thing. It still leaves people wondering, which I really like” (Robinson, 2017, para. 20). Robinson noted the importance of researchers recognizing the multiple ways that people identify rather than lumping people together under imposed colonial concepts. Further, Robinson (2017) stated, “while not all Indigenous sexual or gender minority people identify as two-spirit, the label connects people across Indigenous nations and offers a common name for what were distinct identities or even distinct systems of sexuality” (p. 9). Thus, it is important to note that not all gender diverse Indigenous people identity with the term two-spirit. 12 In another article, Robinson (2019) provided a summary of the term two-spirit and outlined how using this word and identity can only be understood within the context of a particular Indigenous culture and as a conscious way to renew and restore Indigenous culture, language, and understanding of gender. Two-spirit identity was seen as a decolonizing act and two-spirit people have a distinct role to play in protecting and supporting traditional knowledge and language. Robinson (2019) wrote, “The emergence of two-spirit identity coincides with a cultural shift within Settler-dominated communities toward challenging binary categories of sex and gender” (Robinson, 2019, para. 1). Robinson asserted that the eradication of Indigenous languages destroyed Indigenous peoples’ way to describe traditional understandings of gender. Thus, Robinson understood that by reclaiming two-spirit identity a person was reinvigorating the strength of gender and sexual diversity within traditional cultures. Non-binary Non-binary refers to people who understand their gender to be outside of the male/female binary of gender. Other terms that people may use to express similar identities include gender non-conforming or genderqueer. Non-binary people may or may not pursue gender transition to a different gender. For this reason, some gender diverse people may not identify with the term transgender (Matsuno, 2019). Non-binary is sometimes used as an umbrella term to include people who understand their gender to mean both/and, or another gender altogether, or sometimes no gender at all (Cosgrove, 2021; Matsuno, 2019). Barbee and Schrock (2019) write, We acknowledge that not all trans people follow a binary path, many identify as both transgender and non-binary, and some move between such identities. Our point is that like with many identities, these categories are often porous, fluid, and subject to redefinition across one’s life as well as across different cultures and institutions. (p.2) 13 Words and labels provide both an important means of connecting and understanding each other better as well as a way to honour a diversity of experiences. Using the words that people choose for themselves is a significant way to support and validate people. For this reason, best practice calls us to use words that people use for themselves. Losty and O’Connor (2018) reported that once participants found the term nonbinary, they felt able to be comfortable with themselves, and this label became important to their identity. Yet at the same time, identifying as non-binary could elicit feelings of isolation or exclusion when they disclosed this label to others (Losty & O’Connor, 2018). Thus, choosing how and to whom to disclose identity can be an intentional way for non-binary people to create safety and resilience through personal relationships. Gender dysphoria Gender dysphoria is a medical term for the distress felt by some gender diverse people. It is also a formal diagnosis (American Psychiatric Association, 2013) that is frequently required for accessing gender affirming care. For this reason, people wanting to access gender affirming care, may be forced to seek a diagnosis of gender dysphoria. Matsuno (2019) and Elder (2016) advocated for removing gender dysphoria from the Diagnostic and Statistical Manual (DSM-5) as inclusion as a medical diagnosis pathologizes distress around gender as well as gatekeeping access to gender affirming care. Queering To queer, as a verb, can be understood as resisting and being playful about structural roles and norms. Queering can be applied to gender or sexuality to purposefully reconsider social norms. Cosgrove (2021) articulated how study participants discussed queering their visual gender expression by changing their hair or clothing to better match their inward identity and 14 communicate their gender. Cosgrove (2021) wrote, “the creative self-expression that members described as ‘freeing’ and ‘exciting’ was also a tool used to combat erasure. Group members described such forms of expression as a validating way of being seen.” (Cosgrove, 2021, para. 39). Lubitow et al. (2017) found some participants intentionally queered their identity to creatively make subversive statements about gender in public. For example, a non-binary person who was assigned female at birth might intentionally wear their hair in a more masculine way, or chose to wear both feminine and masculine clothing. In this way a person might be making a visual statement about their identity as well as trying to be more authentic to who they are. Health disparities A number of the authors discuss health disparities for gender diverse people, including the effects of trauma. Gender diverse people report poorer overall mental health, and higher levels of anxiety, depression, and suicidality (Rutherford et al., 2021; Snooks & McLaren, 2021). Snooks and McLaren (2021) surveyed 848 gender diverse adults and found that three-quarters of their sample were at high risk for suicidality. Commonly, gender diverse people choose not to connect to health services for fear of being denied care or working with a service provider who is not knowledgeable about their needs (Cosgrove, 2021; Elder, 2016; Lyons et al., 2016). Consequently, not connecting to health services contributes to health disparities for gender diverse people. Specifically considering gender affirming medical care, Lykens et al. (2018) conducted qualitative interviews with gender non-binary adults in San Francisco. Seeking gender affirming care, even from transgender clinics, was found to be binary focused and not inclusive of the needs of participants. Participants who sought medical care to develop a more androgynous look met with care providers who did not understand or pathologized their requests. Consequently, 15 non-binary patients left doctors’ offices feeling unheard or disrespected, and may have not returned to primary care (Lykens et al., 2018). Alternately, some participants used the “trans” label when accessing gender affirming care and then took less than the prescribed dose of hormones so that the effect would be more androgynous. As well, Galupo et al. (2020) found that medical transition did not lessen the effects of gender dysphoria for non-binary people. The effects of discrimination and trauma Gender diverse people often experience harassment and discrimination as impacting their mental health. Galupo et al. (2020) explored gender dysphoria and found for some it was a result of social experiences. Galupo et al. wrote, “Our participants described ways that their gender dysphoria presented as preoccupation with others’ thoughts or intrusive thoughts related to how other people were reading or thinking about their gender” (2020, p. 205). Reisner et al. (2016) found that experiences of discrimination exacerbated symptoms of post-traumatic stress disorder (PTSD) for participants. Further, people who had experienced discrimination reported symptoms of PTSD even without identifying any trauma experiences (Reisner et al., 2016). Galupo et al. (2020) suggested that daily experiences of microaggressions, discrimination, and harassment can cause symptoms similar to PTSD. Consequently, gender diverse people with multiple marginalities (and therefore multiple sources of discrimination), may be at increased risk for PTSD symptoms. In addition, Reisner et al. (2016) found that people who were visibly nonbinary reported more discrimination. Pulice-Farrow et al. (2017) found that people who are nonbinary reported more incidents of harassment and violence. Lord (2020) wrote from a psychological perspective about one non-binary client (called M) who had experienced personal and intergenerational trauma. Using systemic, narrative, and attachment approaches, Lord worked with the client to explore trauma, their relationships, and 16 their gender identity. M’s family had experienced dehumanizing treatment and feelings of otherness, and these feelings were intensified by M’s experiences of otherness due to their gender identity. Further, M’s experiences of gender identity questioned the family’s worldview and ultimately provided a source of family healing. Using psychodynamic and systemic theories as well as narrative tools, Lord worked with M to explore multi-generational traumas, attachments, family relationships and identity. Lord wrote, M's non‐binary identity appears to be an attempt to help their family loosen and widen their worldview about what is possible and necessary in a life. As M questions absolutely everything, stirring things up, they may be serving to organise and activate their family toward healing old wounds and belief systems. (Lord, 2020, para. 23) The trauma M experienced disrupted their attachments and Lord worked with them to own their body and to live as who they truly were. Lord offered a careful consideration of how gender and trauma interacted for M to create a complex understanding of self and of healing. Robinson (2017) spoke about two-spirit people in Canada having two sources of trauma. Both the historical, intergenerational effects of residential school as well as what has happened to all SGD people in Canada continue to cause trauma for two-spirit and Indigenous SGD people. Colonization has erased and shamed traditional understandings of gender and sexuality. These two sources of trauma cannot be separated and must both be considered to work with Indigenous gender diverse and two-spirit people (Robinson, 2017). Knutson and Koch (2021) contributed the idea that for gender diverse people who had previous experiences of trauma and learned (maladaptive) survival skills (such as self-harm or food restriction), these were used to regulate feelings of gender distress, or to withstand experiences of harassment or discrimination. 17 Social implications The social implications of gender diversity are particularly significant for social workers looking to build safety for our clients. As social beings, our gender impacts how we relate to people. Firstly, Cosgrove (2021), Galupo et al. (2020), and Barbee and Schrock (2019) wrote about how gender distress is experienced in social relationships and settings. Pulice-Farrow et al. (2017) studied microaggressions that gender diverse people experienced in friendships. Frequently, gender diverse people who held multiple marginalities reported feeling unsafe in mainstream queer or trans spaces (Cerezo et al., 2020; Coleman-Smith et al., 2020; Cosgrove, 2021; Golriz, 2021; Losty & O’Connor, 2018; Stone et al., 2020b). Finally, gender diverse people experienced barriers to accessing social services (Begun & Kattari, 2016; Lyons et al., 2016), such as transwomen not being allowed to access shelter beds in a women’s shelter. The distress that some felt around their gender was experienced in social settings. Cosgrove (2021) found that, rather than their bodies producing feelings of distress or gender dysphoria, it was “social interpretations of their bodies and expressions that produced discomfort” (Cosgrove, 2021, para. 34). Consequently, some gender diverse people avoided social interactions as a means of decreasing feelings of gender distress (Galupo et al., 2020). Galupo et al. (2020) wrote that social distress can be a reaction to cisnormative stigma experienced in social interactions. Their work was conducted by three researchers with lived experiences of gender diversity. The authors conducted an online qualitative survey with a large sample (n=610) of gender diverse adults to explore the social contexts of gender dysphoria (Galupo et al., 2020). Their study concluded that social contexts included four primary themes which the authors titled: external triggers, internal processing, interruption of social functioning, and moderated by transition (Galupo et al., 2020). Galupo et al. explored how gender dysphoria 18 was fluctuating and responsive to a person’s experiences which might include being misgendered, trans-specific microaggressions, and being consumed with thoughts about social interactions and how others perceive their gender. Galupo et al. (2020) asserted that minority stress theory provided an important tool for understanding gender diversity. Barbee and Schrock (2019) conducted qualitative interviews with 17 non-binary adults to better understand their social experiences and expressions of their gender. Participants discussed how they looked non-binary by choosing to wear clothes or hair styles that would mute the binary gender they might otherwise be perceived as. Simultaneously, when participants felt most comfortable with their visual appearance, they were aware that their androgyny or “ungendering” made others uncomfortable (Barbee & Schrock, 2019). Participants spoke about the emotional work of presenting as non-binary and how it felt authentic to who they were. However, at times participants felt the need to become more binary in order to protect their safety. For example, a non-binary person may try to appear more feminine or more masculine when using a public washroom so that they would be less likely to face harassment or violence (Barbee & Schrock, 2019). Barbee and Schrock quoted one participant as saying, "We live in a very binary world, so pretty much everywhere is unsafe. For my own safety, I have to pay attention to the people around me" (2019, p. 583). A level of constant anxiety and a need for vigilance in public spaces can impact the overall mental wellbeing of non-binary people. Barbee and Shrock (2019) state participants reported that being in public, “evoked fear, vigilant situation assessment, and planning for what-ifs” (p. 11), based on common experiences of discrimination or harassment. Pulice-Farrow et al. (2017) conducted online research of transgender and gender diverse adults with regards to microaggressions that participants experienced from friends. As gender diverse people may rely more on friends due to rejection or expulsion from family, Pulice- 19 Farrow et al. (2017) asserted microaggressions could be particularly upsetting. The authors compared experiences between trans masculine, trans feminine, and non-binary respondents and found many common themes. However, significant differences were also noted between categories of respondents. For example, “friends suggested that transfeminine individuals were not ‘real women’, transmasculine individuals were not ‘real men’ and individuals who identified as non-binary were not ‘really trans’” (Pulice-Farrow et al., 2017, p. 203). In this example, Pulice-Farrow et al. (2017) found friends’ microaggressions to be not only questioning the “realness” of the person’s identity, but also enforcing binary notions of gender acceptance. Finally, the authors noted that gender diverse people of color were likely to experience microaggressions about not only their gender identity but also about their racial background, and that this would compound the distress caused. Unsafe in queer spaces Several articles mentioned how people with a variety of multiple marginalities felt excluded from mainstream queer or transgender communities or services (Cerezo et al., 2020; Coleman-Smith et al., 2020; Cosgrove, 2021; Golriz, 2021; Losty & O’Connor, 2018; Stone et al., 2020b). Cosgrove (2021) and Losty and O’Connor (2018) both found that non-binary people experienced feelings of exclusion from the broader queer community. Losty and O’Connor noted that one non-binary participant felt their queer women friends “perceived their identification with the non-binary gender as rejecting of queer womanhood.” (2018, para. 25). Thus, by trying to live authentically, non-binary people risked exclusion and isolation from queer community. In addition to non-binary people, gender diverse people who also identified as people of colour, neurodiverse, or religious people felt excluded from mainstream queer or gender diverse spaces. Cerezo et al. (2020) noted that women of colour felt they did not fit hegemonic (White) 20 notions of gender or sexual diversity. Similarly, Stone et al. (2020b) found gender policing and racial segregation happened within queer and trans communities. Stone et al. (2020b) noted this segregation is historic and consequently racialized SGD people found community in racialized communities instead. However, race was not the only reason that people felt excluded from queer spaces. Coleman-Smith et al. (2020) found that people with a diagnosis of autism who are also gender diverse might not feel welcome at queer/gender diverse resource centres as the programming and services are not created for the needs of this population (Coleman-Smith et al., 2020). Golriz (2021) found that Muslims also did not feel welcome in mainstream queer spaces. Golriz found that people felt excluded from mainstream SGD spaces for being Muslim. Speaking to intersectionality, one Muslim participant said, People are really racist and will say a thing like ‘[body hair] is disgusting’ without realizing how racialized it is. I went to a queer space recently, and one of the White guys there was talking about how he thinks hair is so dirty. And I was like ‘I have worked so hard to love myself and this is so disrespectful’. (2021, p. 369) People who did not fit the ideal of White, young adult, binary transgender frequently felt excluded from mainstream queer and/or trans spaces and consequently sought support and community elsewhere. Housing and shelter Begun and Kattari (2016) and Lyons et al. (2016) studied homelessness and shelter access for gender diverse people. Both reported discrimination and gender policing around binary genders at shelters that offered beds for only men or women. If staff determined trans women were not feminine enough they were refused access to a shelter bed (Lyons et al., 2016). Lyons et al. wrote, 21 There was a requirement for participants to embody a particular kind of binary feminine gender expression to be welcomed within these services… poverty and economic barriers make this requirement highly unattainable given the costs of make-up, electrolysis, hormones, and so on. (Lyons et al., 2016, p. 376) Services discriminating against gender diverse people resulted in further social exclusions, as well as increasing risk of violence, substance use, and compromised mental and physical health (Begun & Kattari, 2016; Lyons et al., 2016). Begun and Kattari (2016) cited higher rates of homelessness or housing discrimination for gender diverse people (especially racialized gender diverse people), and further that many experienced gender-related discrimination causing homelessness. Lyons et al. (2016) conducted research with 32 trans women in Vancouver’s Downtown Eastside who had accessed women-specific housing or shelter services. Exclusion of transwomen from services for women, although illegal, still proved a common experience for participants. Identity Identity was a major theme in the literature. In considering anti-oppressive practice, articles were chosen to highlight concerns and voices of gender diverse people who claimed a variety of different identities. Firstly, poverty was explored (Kia et al., 2021; Lubitow et al., 2017; Lyons et al., 2016; Rutherford et al., 2021). Next non-binary identities (Barbee & Schrock, 2019; Cosgrove, 2021) were considered. Further, several authors considered race (Cerezo et al., 2020; Elder, 2016; Lubitow et al., 2017), culture (Robinson, 2017), neurodivergence (Cain & Velasco, 2021; Coleman-Smith, 2020), religion/spirituality (Bowling et al., 2019; Golriz, 2021; Elder, 2016), and older adults (Elder, 2016; Porter, 2016). 22 Poverty Poverty was an overarching concern raised by several authors (Kia et al., 2021; Lubitow et al., 2017; Lyons et al., 2016; Rutherford et al., 2021). Kia et al. (2021) conducted a literature review of research of SGD peoples’ poverty in Canada from 2000-2018. Referring to the common misconception of “gay affluence”, Kia et al. (2021) found little research on poverty. However, different demographics had different experiences and reasons for poverty. Regarding SGD newcomers, Kia et al. (2021) believed that people were willing to bear economic disadvantage if it meant that they did not have to return to discrimination, exclusion, violence, or harassment in their country of origin. Kia et al. (2021) found “distinct material disparity in younger and older [SGD] populations, among sexual and gender minorities identifying as racialized and/or newcomers, and among Indigenous [SGD] people” (p. 585). Kia et al. (2021) argued that to ignore poverty for members of this community, is to reinforce intersectional oppression within the SGD community. Due to a greater number of gender diverse people living in poverty, many did not have personal transport and were forced to rely on public transportation where they commonly felt unsafe. Lubitow et al. (2017) researched gender diverse public transit riders and found common experiences of discrimination and harassment. Lyons et al. (2016) noted that poverty can impact someone’s ability to express their gender and that some may create binary gender expressions out of necessity and for their own safety in public. In Canada, gender diverse people were more likely to report being low income or unemployed (Lyons et al., 2016; Rutherford et al, 2021). Lyons et al. (2016) noted correlations between housing insecurity, sex work, few employment opportunities, increased risk for violence, and poorer health outcomes for gender diverse people. 23 Non-binary identities People with non-binary identities had different experiences of identity formation and discrimination than binary transgender people (Barbee & Schrock, 2019 ; Cosgrove, 2021). Cosgrove (2021) conducted participatory action research with nine non-binary coresearchers/participants using photovoice to learn about identity formation and supports for nonbinary people. Themes that emerged included invisibility and erasure. Common experiences included misgendering or assumptions about what non-binary means (commonly White, thin, assigned female at birth), or how someone’s gender expression may or may not communicate their gender experience. Having to explain/defend one’s understanding of their gender “often took a toll on their mental and emotional well-being” (Cosgrove, 2021, para. 27). Non-binary identity formation was often understood by outsiders to be a phase and therefore not respected as its own distinct identity. Barbee and Schrock (2019) wrote about misgendering that non-binary people experienced. Study participants reported that when they were expressing being non-binary, others might perceive them as being sexually diverse instead. One participant stated, “I'm a male who is more feminine [so] most people just think I'm gay” (p. 584). Participants articulated that when living as non-binary, in public they were still understood in binary ways. Barbee and Schrock found that gender diverse people changed their visual appearance to navigate safety. For example, a person might change their behaviour in binary gendered spaces such as a public washroom (Barbee & Schrock, 2019). Race Racialized gender diverse people experience discrimination at both intersecting identities, and might not be able to distinguish which part of their identity was the cause of discrimination. 24 Lubitow et al. (2017) and Cerezo et al. (2020) focused their work on better understanding the intersections of race and gender diversity. Lubitow et al. (2017) explored safety and discrimination for gender diverse people using Portland, Oregon’s transit system. Using a social science lens, they interviewed gender diverse transit riders, specifically seeking racialized participants (n=9/25), and their sample included people who were Black, multiracial, Indigenous, and Korean. The authors found that White transmasculine respondents reported fewer incidents of violence and harassment. Lubitow et al. found that “certain forms of privilege can mitigate experiences of harassment and discrimination” (2017, para. 10). Twenty-two participants (out of twenty-five) reported incidents of harassment or discrimination on public transit property. Safety and harassment were considerations in how participants expressed their gender when using public transit. Gender expression became closely aligned with safety and survival rather than with authenticity (Lubitow et al., 2017). Lubitow et al. (2017) contributed valuable research that was intentionally inclusive of people with marginalized gender identities regarding their experiences of safety and harassment on the public transit system. Historically, racialized gender diverse people might not have access to gender affirming care. Elder (2016) quoted one participant who spoke about a prominent endocrinologist in San Francisco who, “only gave hormones to White girls he thought would pass. Others he gave water shots instead of hormone shots” (Elder, 2016, p. 182). Consequently, not only was agency of their body denied to gender diverse racialized people, but a clinician’s understanding of acceptable binary gender was justification for rejection of gender affirming care. Cerezo et al. (2020) conducted interviews in California with 20 black, multi-racial, and Latina gender diverse women to better understand how intersectionality affected identity formation. A clear theme that emerged was the strong influence of family who imposed 25 gendered/cultural expectations, and pressure to remain silent about their identity for the benefit of the family as a whole. For example, “four participants noted that within their community of origin, parents were regarded as responsible for their child’s sexual orientation. As a result, parents were reprimanded and/or shunned by other family and community members” (Cerezo et al., 2020, p. 73). Some participants spoke of creating major life shifts away from family (going away to college or joining the army) in order to explore their gender or sexual orientation. Cerezo et al. (2020) saw it as imperative that support services work with clients to better understand the social networks people have and how intersectionality affects overall health. Culture Robinson (2017) wrote from personal experience and from her research where she explored whether two-spirit identity can be considered under the bisexual “umbrella” for research purposes. Indigenous peoples’ experiences were shown to be different because of colonization, and to not study two-spirit communities specifically was seen as an act of colonial erasure (Robinson, 2017). Conversely, reclaiming the term two-spirit was an act of resistance and of reclaiming what colonization and Christianization erased and eradicated from Indigenous culture. Reclaiming the term two-spirit could bring a reconnection to culture, and a source of resilience for two-spirit people (Robinson, 2017). Neurodivergence Cain and Velasco (2020) used a narrative inquiry approach to interview one non-binary person (called Grey) who lived with autism spectrum disorder. Using research as a platform to amplify Grey’s voice and story, the authors explored the intersections of gender identity and dis/ability. Although Grey had experienced stigma and bullying they recognized the need for gender to be fluid, and that transitioning can be fluid, too. Cain and Velasco (2021) found that 26 Grey’s negative experiences of gender affirming care affected their, Grey’s, choices around transitioning and deciding what gender best fit for them. The authors found that, for gender diverse people, their gender may not be the biggest stressor in their lives, and their gender may not need to be clear and defined. As well, Grey discussed how they were denied gender affirming care due to being overweight, yet going to a gym could be unsafe for a variety of reasons. Cain and Velasco (2021), used narrative inquiry to elucidate the various intersections of Grey’s identity that impacted their health, health access, and understanding of their identity and gender. Noting high prevalence rates for people diagnosed with autism to express gender diversity, Cain and Velasco called for specialized supports to consider these two intersecting identities. Coleman-Smith et al. (2020) conducted interviews with 10 adults who were diagnosed with both autism spectrum disorder and gender dysphoria. Their work highlighted how people with neurodevelopmental differences experienced heteronormativity and ableism from service providers who dismissed their struggles. One participant stated, “Autistic people can end up with mental illnesses because they’re being told their truth doesn’t exist” (Coleman-Smith et al., 2020, p. 2648). Another participant clearly articulated the challenge they faced because of being autistic (a distinctly social challenge) as well as trying to re-learn how to socialize in a new gendered way. They stated, I don’t feel like I’m fully socially transitioned because I am experiencing more autism barriers than I was as a woman…I had thirty odd years to learn how to pretend to be female…and I’m still trying to come up with new strategies to be consistently read as male because expectations are different…Autism makes this slow. I’m also being read more as autistic because I’ve not learned the disguises for someone now read as 27 male…My confidence is affected…so more autistic behaviour, like stim[ming] creeps out. (Coleman-Smith et al., 2020, p. 2652) One key finding of Coleman-Smith et al.’s work (2020) was of the need for social supports. Mentoring and online supports may better serve people who are gender diverse and have diagnoses of autism. The authors’ findings highlight the need to better support people with these specific intersections. Religion/ spirituality When gender diverse people were able to find religious community or spiritual connection, this provided a valuable source of support (Bowling et al., 2019). Golriz (2021) found inclusive religious organizations understood themselves to provide safe places for people to create and strengthen their multiple marginalities. Unfortunately, experiences of harassment or discrimination in the mainstream spiritual community were common for gender diverse people, and this was a particular concern for older adults as this time of life is when many seek spiritual and religious connection (Elder, 2016). Golriz (2021) researched the sexually and/or gender diverse Muslim community in Toronto, conducting interviews with 24 leaders at various organizations. Golriz found in this community an alternative to both the mainstream queer and trans community and to the mainstream Muslim community that resisted the hegemony of both and supported inclusion and diversity. As members shared experiences of transphobia, homophobia, racism, and Islamophobia, these organizations provided safety for people to heal. Golriz wrote, queer and transgender Muslim organizations [QTMOs] “challenge mainstream groups’ failure to uphold safety for [SGD] Muslims” (2021, p. 369). QTMOs provided a place where people could define their identities for themselves, rather than feeling pressure to look or act a certain way to visually 28 signal gender or sexual diversity to all. Golriz found QTMOs provided a safe and inclusive place for support, grounded in shared faith and religious community. While QTMOs were found to provide a place to heal and grow in resilience, similarly two-spirit identity provided a means of reconnecting to culture and traditional spirituality. Robinson (2017) reported that two-spirit identity itself was a spiritual identity and “was reported to emerge in response to events in the spirit world, accessed through dreams or visions” (para. 29). In this way, reclaiming two-spirit identity was to reclaim that spiritual role, tradition, and connection. Older adults Two articles (Elder, 2016; Porter et al., 2016) created recommendations for working with older gender diverse people. The authors found that some older adults transitioned later in life due to family relationships and experienced isolation in current gender diverse services whose users are commonly much younger when beginning to access gender affirming care (Elder, 2016; Porter et al., 2016). Porter et al. (2016) wrote recommendations for working with older gender diverse adults, noting many gender diverse older adults had experienced discrimination throughout their lives. Identity documents posed difficulties for older gender diverse people, as these were needed to access long-term care, housing for older adults, or retirement communities. If people’s lived gender did not match their ID documents, they faced discrimination or rejection of their gender identity. As a result of past discrimination with medical care providers, gender diverse older adults might choose not to disclose their gender to new care providers, which could lead to medical complications such as polydrug interactions (for example between hormones and other medication). To avoid discrimination or harassment, gender diverse older adults reverted to 29 gender expression that matched the sex assigned at birth, or even planned suicide rather than entering long-term care facilities. Finally, nearing the end of life, some gender diverse people feared being misgendered at death or on their death certificate. Porter et al. (2016) provided a conclusive overview of anxiety, concerns, and policy affecting older gender diverse adults. Resilience Resilience as a source of healing and connection was a common theme. As social workers, resilience is a tool to resist deficit-focused models of understanding (such as the medical model). This theme can further be broken down into studies of protective factors, and counselling modalities that support resilience building when working with gender diverse people. Protective factors Bowling et al. (2019) conducted a longitudinal, qualitative study on resilience. Using photography, participants were asked to reflect on the question, “How are you strong (or not) and what does strength look like?” (Bowling et al., 2019, para. 6). Although experiences of distress were common, participants shared unique insights into what resilience looked like. The authors noted how resilience was not static and was shown to shift or change over time. Social supports offered either a source of resilience or of distress. Food, hobbies, and advocacy were discussed as ways of exploring resilience (Bowling et al., 2019). Beischel et al. (2021) conducted an online qualitative survey to better understand gender euphoria and people’s experiences of it. Whereas gender dysphoria is a diagnostic term from the medical profession, the term ‘gender euphoria’ was created by gender diverse communities. Beischel et al. quoted one participant who described gender euphoria as, “the electric feeling of happiness and excitement in expressing one's gender, especially when that gender identity and expression are marginalized or ostracized” (2021, p. 11). Beischel et al. (2021) further described 30 gender euphoria as “a joyful feeling of rightness in one’s gender/sex” (p. 13). Gender euphoria created feelings of attractiveness and confidence for participants. Some participants experienced gender euphoria as intense and fleeting in contrast to chronic gender dysphoria. People’s experiences of gender euphoria were varied and sometimes contradictory. The authors noted that for non-binary participants, feelings of gender euphoria might arise from an awareness that strangers are uncertain of their gender. Beischel et al. (2021) argued that unlike the medical idea of gender dysphoria, which was classified in a way that fits some but not all gender diverse people’s experiences, gender euphoria is an opportunity for people to narrate their own understandings and experiences of joy around gender. Beischel et al. reconsidered minority stress theory to understand how gender affirmations provided additional sources of resilience. Gender euphoria could be an alternative way to understand gender diversity and to assess what gender affirming care would best suit people’s needs (Beischel et al., 2021). One common source of resilience is inclusive community. Bowling et al. (2019) noted that gender diverse people found connection and shared medical information about affirming care through community connections. In addition, social supports found in community reduced isolation and loneliness (Bowling et al., 2019). Stone et al. (2020b) conducted participatory action research asking how community contributed to resilience. Stone et al. (2020b) found differences in community depending on the interviewee’s racial background. Gender diverse people of colour were more likely to find community with queer communities of colour. White gender diverse people were more likely to find community with hobbies or interest groups that attracted predominantly White people (such as the cosplay community). The authors noted that the importance of community was clear. They write, “regardless of race or age, almost all interviewees described the importance of developing supportive trans or non-binary social 31 networks, whether in person or online” (2020b, p. 237). Thus, being in a community offered a protective measure for participants. Having role models was also a protective factor. Rider et al. (2019) found that non-binary people found role models in gender diverse communities. Learning how to navigate gender diversity and anticipate barriers, as well as finding solidarity, all served as lessons in resiliency learned from role models (Rider et al., 2019). Stone et al. (2020a) found that for gender diverse people of colour, role models were found in their family of origin. Stone et al. (2020a) argued that participants found role models in strong, resilient mothers and other mothers (grandmothers, sisters, aunts, etc.). Black and Latinx participants looked to these women to find models of how to navigate adversity, discrimination, and marginalization and used these tools to become resilient when facing homophobia, transphobia, or other forms of discrimination. These strong women taught resistance and resilience through their actions. In addition, fathers and men in the family were seen to have important roles in teaching about masculinity and racial identity. Thus, regardless of the gender of the role model, they provided a source of strength and resilience. Affirmative counselling to support resilience Several authors (Elder, 2016; Knutson & Koch, 2021; Matsuno, 2019; Rider et al., 2019; Singh, 2016; Snooks & McLaren, 2021) explored different ways of supporting gender diverse people. Social workers, and other support workers, could best serve this population by doing ongoing self-reflection of their own understanding of gender (Knutson & Koch; Matsuno, 2019; Singh, 2016). Psychoeducation was found to provide resources and agency to gender diverse people and might include providing information about gender affirming care (Knutson & Koch, 2021), the effects of hormone therapy on mental health (Elder, 2016), and minority stress theory (Matsuno, 2019). Gender affirming supports provided a safe place to explore gender and identity. 32 Historically, the medical system supported only binary gender expressions while nonbinary genders were pathologized (Rider et al., 2019). Matsuno (2019) emphasized how gender diverse identities are often understood in the process of transition from one gender to another, erasing genders that are non-binary. Thus, gender affirming supports need to have an understanding and sensitivity to non-binary identities. With an understanding of non-binary identities, clinicians provide care that is truly gender affirming without putting expectations around a patient’s gender identity or expression. Rider et al. (2019) explored a psychological framework for affirmative care, specifically with non-binary or genderqueer people. Non-binary patients seeking medical transitions might present with binary genders in order to access needed care. Rider et al. (2019) recommended supporting people to engage with non-binary specific supports, which are available online, if not locally. Informed by the discipline of sex therapy, Rider et al. recommended exploring pleasureoriented sexuality with the client, which could involve psychoeducation around naming body parts in ways that did not cause dysphoria, as well as how to negotiate empowering sexual relationships. The model explored by Rider et al. (2019) was a specific enhanced way to support non-binary people through psychotherapy. Matsuno (2019) wrote an explanatory article aimed at considering how to work on micro, mezzo, and macro levels to best support non-binary persons. Matsuno’s article considered how language use could be a source of distress for non-binary people who were frequently misgendered. Matsuno (2019) recommended including careful and thoughtful use of pronouns with clients (micro level); working with families of non-binary youth to normalize gender diversity and encourage family acceptance as a protective factor (mezzo level); and advocating for systemic changes that would create safety for non-binary people (macro level). 33 Elder (2016) conducted qualitative interviews with gender diverse older adults (ages 6083) focused on participants’ experiences with psychotherapy. All participants described hurtful or harmful experiences they had with therapists including being restrained, overmedicated, or enduring sexual advances. Participants offered suggestions to other gender diverse people, including finding peers for support, and planning to take someone to the emergency room, or hospital visits. Participants from Elder’s study (2016) recommended having a gender exploration closet available so that people could try on clothes and really explore gender in a safe environment. Participants also recommended that sliding scale fees for counselling services allowed for more equitable access. Knutson and Koch (2021) wrote about their experience working with one gender diverse client. Using co-therapy supervision, the two psychologists worked together in a mentoring relationship with the client as a way “to build competence” (Knutson & Koch, 2021, p. 370) for gender affirming practitioners while also providing experienced professional care. Knutson and Koch (2021) lay out the steps they used to work in an affirming, person-centred way with a nonbinary client. These steps included rapport building, psychoeducation, transition exploration, social support and assertiveness, letter co-creation (needed for accessing gender affirming care), and termination preparation. The client that Knutson and Koch worked with had a number of presenting mental health concerns including self-harming behaviour, restrictive eating, and suicidal ideation. By focusing primarily on gender affirmation and exploration, the overall health and wellness of their client improved. Singh (2016) wrote an article to apply the theory of liberation psychology to working with gender diverse people. Liberation psychology comes from work in Latin America and teaches psychologists to analyse and reflect on their own experiences of power and, in this 34 situation, on their understanding of gender. Singh encouraged psychologists to move towards working with gender diverse people with the understanding that gender liberation is inherently connected to those most marginalized by gender. Singh called psychologists to move beyond affirmative psychology (which inherently creates distance between the psychologist and the client) to a place where it was more personal, where all were affected by the gender binary and our society’s gender roles and rules. Gender nonconformity could be experienced by people who are cisgender and people who are gender diverse (Singh, 2016). Singh encouraged psychologists to name oppressive systems with clients and to work with clients in finding ways to safely resist oppression. Singh recommended that cisgender psychologists engage the expertise of gender diverse clients about how to better serve gender diverse people. Snooks and McLaren (2021) conducted an online international survey with gender diverse adults to learn about how dispositional hope might provide resilience and affect suicidality. Snooks and McLaren defined dispositional hope as “a motivational and positive psychological state that allows individuals to overcome challenges and reach desirable goals” (2021, p. 58). Dispositional hope is a practical hope that connects to targets, and that the person believes they can achieve. Specifically, Snooks and McLaren examined how the idea of burdensomeness, (or how much the person perceives of themselves as a burden on others) and how it related to suicidality. The authors concluded that, “results indicated that dispositional hope is potentially protective against suicidal ideation and behaviors at low but not high levels of perceived burdensomeness among [gender diverse] adults” (Snooks & McLaren, 2021, p. 65). The authors called for more study on dispositional hope and how it might be used as a tool to address high rates of suicidality for gender diverse people. 35 Discussion Social workers can provide support to gender diverse people to allow them to safely explore gender and build resilience. Social workers can intentionally and carefully create practices that are affirmative of gender diversity. As anti-oppressive social workers, selfreflection is an inherent part of how we best serve whoever our clients are. In program or organizational development, social workers are well positioned to provide trauma-informed and inclusive spaces informed by the needs of gender diverse people. Anti-oppressive practice compels social workers to consider how to include gender diverse people in conversations about improving equity and overall wellness. Implications for Social Work Practice Few sources were specifically written through the social work lens. Exceptions include Baines (2017), Begun and Kattari (2016), Cosgrove (2021) and Kia et al. (2021). However, the vast majority of sources come from a variety of other disciplines but offer significant implications for social work practice at the micro, mezzo, and macro levels. Clark (2016) raised the importance of not only lifting up strengths but also listening for the resilience and resistance of the storytellers. Those with experiences of gender diversity have strength and have learned to survive in a world where their identity is a challenge to social norms. As social workers, we need to amplify the stories of discrimination and violence and simultaneously honor the resilience and strength of the story tellers. Social workers can learn from these stories about strength, resilience, and what equity could look like. To best support gender diverse people, social workers must start with self-reflection. Consideration for how we understand our own gender, and the genders of others, is essential. As well, we must start with an understanding that gender can change over time. Consequently, 36 checking in with people around pronouns is an ongoing practice of inclusivity. Singh (2016) called us to understand that gender liberation will be best informed by those most marginalized by current gender constructs. Thus, we need to provide opportunities to listen and have the voices of gender diverse people be heard and respected. Further, social workers need to be informed about local gender affirming care, what that looks like, and how to access services. We must take it upon ourselves to learn about the effects of hormone therapies on mood, mental health, and the physical body. Micro There are numerous ways that social workers can intentionally support individual gender diverse people. Targeted education on minority stress can build resilience around responding to microaggressions and reducing feelings of stigma (Matsuno, 2019). Psychoeducation could also introduce what gender affirming care looks like in the area where the client lives, and what options are available. In addition, social workers could introduce clients to expectations around the effects of hormone therapies on mood and body. Further, clients could be introduced to local or online communities of peers for support and information. Mental health should be a consideration for working with gender diverse people. Minority stress theory provides an understanding of how discrimination, harassment, stigma, and daily microaggressions can impact the mental health and well-being of gender diverse people. Reisner et al., (2016) wrote about how minority stress can cause symptoms of trauma in gender diverse people even without other traumatic experiences, thus, it is imperative that social workers practice from a trauma-informed way and with an understanding that trauma may impact the decisions and behaviours of gender diverse people. With high rates of suicidality, 37 anxiety, and depression, suicide risk assessment and resources for mental health supports should be made readily available to gender diverse people. Social workers create safety for marginalized people. Thus, we can provide a safe place for people to explore gender identity, what that means for them, and how and if they want to disclose their identity to others. Matsuno wrote, Clinicians can help their clients decide who they want to disclose their affirmed name and pronouns to and strategize how to do so…The clinician can help the client weigh the risks and benefits of disclosure and nondisclosure in different contexts, such as among friends, family, co-workers, and strangers. (Matsuno, 2019, p. 623) Social workers can provide a space to think through changing gender and the implications, exploring language, names, and pronouns with clients to find what best aligns for them. Elder’s study (2016) recommended having a gender exploration closet available for people to safely explore clothing options. As well, Elder (2016) noted that providing sliding scale fees created more equitable access to services for people that may face financial hardship due to their gender expression. Beischel et al. (2021) recommended working with an understanding of gender euphoria to affirm experiences of gender joy as a means of building resilience. Clark (2016) held up the importance of storytelling and in recognizing the pain and trauma, as well as the strength and resilience, of the storyteller. We as social workers can gently hold these stories, witnessing both the pain, beauty, and resilience of gender diversity. Social workers can intentionally affirm resilience in gender diverse clients, holding it up as a valuable strength. Finally, anti-oppressive practice contributes to social work ideas of how multiple oppressions that people may experience contribute to health, mental health, and social 38 marginalization. For example, Pulice-Farrow et al. (2017) noted that gender diverse people of color were likely to experience microaggressions about not only their gender identity but also about their racial background, and that this would compound the distress experienced. Thus, if social workers apply an anti-oppressive lens they are able to better understand and support people with multiple marginalized identities. Mezzo Mezzo level interactions for social workers to support resilience include designing and adapting programs and services to be more responsive and inclusive of gender diverse people. Specific changes recommended by Lykens et al. (2018) include amending intake forms so that gender variety is possible. Kia et al. (2021) recommended consultation with people with lived experiences when planning programs and services. Further, social workers can create agency culture where gender is understood to be fluid and where there is room for ongoing exploration of gender at all ages. Trauma-informed care is an essential social work practice. Like anti-oppressive practice, trauma-informed practice is never completed, but always a work in progress. One role for a trauma-informed social worker is to provide a valuable reminder on a multidisciplinary team to other staff about how people with lived experiences of trauma may have developed survival skills that produce challenging behaviour. Social workers can ensure compassion for all staff and clients to understand how trauma informs interpersonal behaviours. For example, people with experiences of childhood trauma may be slower to develop relationships of trust and consequently may take longer to develop rapport and trusting relationships with service providers. In a busy medical setting, clinical staff may not feel that they have the time to develop 39 rapport, unless they are considering the long-term importance of keeping clients engaged in healthcare services. Social workers can be a part of clinical care teams, or as liaisons to primary care teams, to advocate for the specific needs of non-binary people. Lykens et al. (2018) called for greater awareness at primary care clinics of the needs of gender diverse people who are non-binary. Using our training and authority as social workers, we can encourage physicians and nurses to be prepared for non-binary conversations about gender. As we centre and amplify the needs and wishes of the clients we work with, we can advocate for medical services that take primary direction from the patient. Matsuno (2019) called for the use of the informed consent model of care. In this model, clinicians would explain the risks and side-effects of any requested gender affirming care and the patient would decide the best course of action. Rather than relying on a diagnosis of gender dysphoria, this model empowers the client as expert in their own understanding of gender and supports non-binary gender identities. Social workers can encourage clinical models to support informed consent. Using an anti-oppressive lens, social workers must build decolonizing programming and services, informed by Indigenous gender diverse people. Working with Indigenous gender diverse people requires a willingness to change structures and systems to incorporate Indigenous knowledge and traditions. Social workers must make the space safe and welcoming by inviting participation and honest feedback from Indigenous gender diverse people, and Indigenous communities. We must fundamentally change our programs and services to be active agents of decolonization. Social workers can advocate with employers to create relationships and consultation with local Indigenous people and communities to better inform programs, services and how to make spaces inclusive and safe for gender diverse Indigenous and two-spirit people. 40 Social workers involved with queer services can, alongside gender diverse people, ensure that queer spaces are safe for all gender diverse people. Social workers can advocate for advisory committees to ensure intersectional and non-binary gender diverse people give feedback on programming and services. Macro Social justice social work calls for systemic change. Kia et al. (2021) call for social workers to engage with youth, older adults, newcomers, Indigenous, and racialized SGD people to empower voices of people with lived experience and their specific needs around advocacy. Social workers can centre voices of people with lived experiences when advocating for change. In terms of big picture and societal change, social workers can play a unique role informed by their practice. Begun and Kattari noted that social work is a place to engage in larger conversations to change understandings around gender binaries and how “passing” can be oppressive to non-binary people. Begun and Kattari (2016) call for creation of inclusive policy in response to “the sheer numbers of [gender diverse] individuals experiencing harassment and physical and/or sexual assault in homeless shelters” (Begun & Kattari, 2016, para. 12). Thus, social workers can engage with their organizations and with coalitions to raise awareness about exclusionary policies and how these affect gender diverse people. Matsuno (2019) and Cosgrove (2021) advocated for the removal of gender dysphoria from the Diagnostic and Statistical Manual as the gatekeeping function of this diagnosis does not serve non-binary people well and limits access to care that may be health promoting. Antioppressive practice compels us, as social workers, to speak to the power dynamics of the diagnostic model versus the informed consent model of care. 41 Finally, on witnessing the beauty and pain of gender diversity, social workers can get involved with local Transgender Day of Remembrance, and Transgender Day of Visibility, and seek out sources of gender euphoria through local or online art. Further, social workers can deconstruct gender and the need for gender constructs in our services, policy, and in society in general. Gaps in literature I wanted to focus this paper on trauma and resilience of gender diverse people. However, although I was able to find sources that spoke to trauma and gender diversity, there were not enough to focus so narrowly on this topic. I found a number of sources that spoke to issues of resilience and how resilience is related to trauma for gender diverse people (Cain & Velasco, 2021; Clark, 2016; Elder, 2016; Golriz, 2021; Hendricks & Testa, 2012; Lord, 2020; Meyer, 2003; Reisner et al., 2016; Robinson, 2017; Robinson, 2019; Stone et al., 2020a; Stone et al., 2020b). Experiences of trauma were diverse and widespread and included historical or colonial trauma (Robinson, 2017; Robinson, 2019), intergenerational trauma (Lord, 2020), individual/personal trauma (Cain & Velasco, 2021; Elder, 2016), and trauma due to racialized or otherwise marginalized identity (Golriz, 2021; Stone et al., 2020a; Stone et al. 2020b). Practicebased research on resilience for gender diverse people that was used in this paper focused on counselling modalities or affirmative models of care. Resilience research was informed by minority stress theory (Meyer, 2003), and consequently was a response to common experiences of discrimination for gender diverse people. Consequently, the research found shifted from trauma specifically to discrimination and resilience for gender diverse people. In reading the articles, I noticed a lack of non-binary experiences articulated in transgender literature. Lykens et al. wrote, “Increasingly, research is focusing on the health and 42 healthcare experiences of gender-diverse populations. However, this work has focused disproportionately on trans men or trans women, largely ignoring genderqueer and non-binary (GQ/NB) individuals” (2018, p. 191). This recognition led me to seek out research on non-binary experience specifically. Looking for non-binary research made me aware of other significant gaps in research, for example, how disability affects gender diversity. I found two (Cain & Velasco, 2021; ColemanSmith, 2020) relevant articles on autism spectrum disorder and gender diversity, but no research on other intersections of gender diversity and disability. Thus, how disability and gender diversity interact appears to be an area of knowledge which would provide rich anti-oppressive learning for social work. Many of the authors used for this literature review noted the lack of racial diversity of their sample. The exceptions (Cerezo et al., 2020; Golriz, 2021; Stone et al., 2020a; Stone et al., 2020b) focused specifically on racialized (non-Indigenous) participants or communities to better understand their unique concerns. Beischel et al. (2021) noted that as racialized gender diverse people have less access to gender affirming care, this might mean less access to gender euphoria as well. As gender is deeply impacted by culture, this lack of diversity in many of the samples has almost certainly led to a lack of diversity in understanding resilience, strengths, and experiences of how gender diversity and race have broader implications. Further, gender diverse Indigenous people’s experiences and voices were not well represented. I found only three relevant articles (Clark, 2016; Robinson, 2017; Robinson, 2019) that looked at gender diversity with a Canadian decolonizing lens. Robinson (2017) calls for research on Indigenous people specifically because the diversity of cultural understandings about gender, to not do so is to continue the colonization of Indigenous ways of knowing. 43 Age was also a noticeable gap as most studies had a median age for participants in their 20s or 30s, unless they were specifically focusing on older adults. Thus, older adult experiences are not well represented and studied. Yet Elder (2016) and Porter et al. (2016) spoke about the unique needs and concerns for this population. I found that young, White binary gender diverse people comprise the majority of participants of most studies, unless the study focused specifically on an intersection of gender diverse experience. Thus, people who are other than young, White and/or binary may have experiences not well captured and articulated by research. I wondered whether this has to do with White supremacy and how it shows up in queer and trans communities. Further research to seek out experiences from gender diverse people who are not young, White, and able-bodied would significantly enhance our understanding of experiences gender diversity in Canada. The academic sources used for this literature review did not address the needs and experiences of non-binary people who are accessing shelter or housing services. This area would be a distinct area of future research to consider from social work and anti-oppressive lenses. I was unable to find any recent relevant literature on immigrants, refugees, and/or newcomers to Canada specifically. As immigration laws differ by country, researching this population would provide significant knowledge to better understand gender diversity as part of acculturation to Canada. Finally, more research on religious or spiritual communities that offered safety and healing for gender diverse people would be useful as faith communities have potential to provide connection, belonging, and places for healing and growth. Future research is needed on specific under-researched populations of gender diverse people including newcomers to Canada, older adults, people with disabilities, and religious or 44 spiritual communities. Also, explorations around gender fluidity and how this interacts with accessing gender affirming care would be relevant for social workers. As well, research to better learn how to create safety for gender diverse people in queer spaces would provide important knowledge for social work. Gaps in current research provide a number of directions for future research on how social work can best support gender diverse people. Gaps in research serve to highlight the important role that social work can play in creating more equity for gender diverse people. Conclusion Using anti-oppressive theory, red intersectionality, and minority stress theory, this paper explores how the intersections of gender diversity, race, and culture play roles in identity. Emerging themes from a review of recent relevant literature include language (especially pronoun use, relevant terms and use of language as a means of welcoming and affirming gender diversity), health disparities and social implications for gender diverse people, identity (poverty, non-binary identity, race, culture, neurodivergence, religion or spirituality, and aging), and finally resilience. Social work can contribute important insights to public health and psychology holding up the resilience and strength of gender diverse people and communities. Further, social workers can learn from careful listening to gender diverse people about how best to address disparities in healthcare. Further, social workers can play a significant role in building safe programs and services to support the resilience of gender diverse people. Social workers have the power to create culturally safe and inclusive practices and significantly contribute to the social determinants of health for gender diverse people. 45 Anti-oppressive social work practice calls us to be self-reflective about our own understandings of gender and to work alongside people with lived experiences of gender diversity to create equity, safety, and inclusion. As individuals, social workers must first examine ourselves, how we came to understand gender and how we understand our own gender. Then we must listen closely and continually to people with experiences of gender that are different from our own. An examination of power around gender needs to be ongoing and is crucial to building just communities. As social workers we can queer our own understanding of gender, challenging ourselves and our institutions to be fluid. We can learn from non-binary people about how binary genders are oppressive. 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