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Assessment/Evaluation with Transgender and Non-Binary (TNB) Youth
Dear Assessment Committee,
What best practices should be considered when completing a psychoeducational assessment/evaluation with Transgender and Non-Binary (TNB) youth?
In order to further this topic of discussion, the Assessment Committee feels it is important to provide context related to the topic from national sources such as the Human Rights Campaign, American Psychological Association, The Trevor Project, and American Civil Liberties Union. Though these are helpful sources for data, there are limits to any information that will be provided as this is an area that has historically received limited attention in research, literature or guidance in practice. Studies that use inclusive practices to identify Transgender and Gender nonconforming participants are also extremely rare, and as such, this is an area of evolving information, and one that will likely need to be revisited regularly by practitioners in order to stay up-to-date on the elements of best practice related to working with youth who may be a part of this population.
The Assessment Committee also would like to note that many of the terms and topics covered in this discussion stem from research articles and guidelines that may address information through the lens of cisnormativity, or the idea “that cisgender identities are the norm, and that variation from the gender binary is abnormal” (Tebbe & Budge, 2022). As the visibility of the transgender and non-binary community continues to grow, likely so shall the breadth and depth of research related to how best to support and uplift their needs and strengths. The Assessment Committee remains committed to examining research and policy related to these areas as they continue to develop.
To further this idea, the APA encourages all practicing psychologists to be aware of multiple and intersecting identities. Therefore, consideration should be given to a students’ complex identities, and that there are multiple factors that intersect to create a persons’ self-definition, including but not limited to “culture, language, gender, race, ethnicity, ability status, sexual orientation, age, gender identity, socioeconomic status, religion, spirituality, immigration status, education, and employment, among other variables” (APA Multicultural Guidelines). While these factors may be considered at any point, they are also key to conceptualize that a persons’ identity, and what role/form that identity takes, is a fluid idea. Or to put it simply- the importance of different elements of a person’s identity are unlikely to remain static their entire life. As the APA states in their multicultural guidelines “..identity development is…influenced by structural and interpersonal factors… influenced by structural oppression and privilege, historical trauma, migration, and dislocation.” That is to say, that the role that any one factor will play for a child or student will likely depend heavily on the context of their individual history and experiences at any given time in their development.
Legal and Ethical Implications:
To ensure assessment provides accurate results, the assessment must be conducted in a manner that affirms the student’s gender identity (Schools in Transition). Many assessments and rating scales are normed on binary individuals, and some measures require examiners to select gender for scoring purposes but only provide binary options (e.g., male, female). Though NASP does not have specific guidance on this topic for school psychologists, APA posits, “Psychologists do not have a standard for determining what scoring template to use. Providers should remember clients possess intersectional identities and that identity and self-definition are both shaped by multi-faceted social contexts for each client.” This idea was echoed in an excerpt from a recent systematic review of studies about mental health of TNB youth by Tankersley et al. (2021):
“Several evidence-based child and adolescent assessments, ranging from IQ testing to clinical self-report questionnaires, are normed on groups of boys and girls, and scored accordingly. This poses challenges for the assessment of TGNC youth. Some studies opt to score the assessment based on the child’s assigned sex at birth. In a review of the role of hormones on the transgender brain, Nguyen et al. (2019) found that the majority of included studies indicated that the brains of transgender people are more similar to their identified gender in terms of cerebral matter volume, gray matter volume, and performance on verbal and spatial tasks; they further found that gender-affirming hormone therapy can enhance this neurological similarity to a transgender person’s identified gender. Even if clinicians take an affirming stance and score and interpret assessments based on the child’s identified gender, this does not elucidate a solution for gender nonconforming youth who do not identify as a boy or as a girl.” - (Tankersley et al. 2021)
However, If a clinical is choosing to use rating scales for students who identify as trans or nonbinary, it is advised that they should consider using assessment tools for which combined gender norms are available, such (Exp: BASC-3 or Conners-4). The use of combined gender norms is strongly encouraged over gender-specific norms. There is also no requirement to report the gender of norms used. There is also potential to utilize scales or measures that may not use gender as a factor in their norming, particularly in instances where the student’s gender/nonbinary status may be a point of disagreement amongst parents/caregivers (Examples include: SCARED, RCMAS-2, BDI-2). Ultimately, as with any special education evaluation, decision-making should happen through multiple data points, collected from multiple sources, by multiple methods.
While it is important to partner with most student’s during the evaluation process, there may be a heightened need with evaluations of TNB students to practice transparency throughout the process. This may include informing them of the purpose of the evaluation, where the information will be shared and who will have access to the contents of the report. The clinician should also ask the student how they would like to be referred to within the report, particularly once they have the knowledge of who it will be shared with. It is also advised that all practitioners prioritize developing, and using, report templates that have inclusive language. NASP's Standard I.2.5 Privacy Related to Sexual Orientation and Gender Identity and Expression states that school psychologists “do not share information about the sexual orientation, gender identity, or transgender status of a student (including minors), parent, or school employee with anyone without that individual’s permission.” And as stated by the NASP Position Statement for Safe and Supportive Schools for Transgender and Gender Diverse Students (revised in 2022), disclosure could lead to potential harm of the individual, even with beneficent intent, and may be a violation of state or federal laws.
American Psychological Association. (2017). Multicultural Guidelines: An Ecological Approach to Context, Identity, and Intersectionality. Retrieved from: http://www.apa.org/about/policy/multicultural-guidelines.pdf
Johns MM, Lowry R, Andrzejewski J, et al (2019). Transgender Identity and Experiences of Violence Victimization, Substance Use, Suicide Risk, and Sexual Risk Behaviors Among High School Students — 19 States and Large Urban School Districts, 2017. MMWR Morb Mortal Wkly Rep ;68:67–71.
Keo-Meier, C.L.; Fitzgerald, K.M. (2017) Affirmative psychological testing and neurocognitive assessment with transgender adults. Psychiatr. Clin. N. Am. 40, 51–64.
Parker, K., Graf, N., & Igielnik, R. (2019). Generation Z Looks a Lot Like Millennials on Key Social and Political Issues. Pew Research Center's Social & Demographic Trends Project. Available at: https://www.pewresearch.org/social-trends/2019/01/17/generation-z-looks-a-lot-like-millennials-on-key-social-and-politic al-issues/ Accessed on June 17, 2021.
Ryan, C. (2021). Increasing family support to build healthy futures for LGBTQ students [Webinar]. National Association of School Psychologists 2021 Annual Convention.
Rebecca M. Harris MD, PhD, MA, Joel E. Frader MD, MA. (2019). Pubertal Suppression in Transgender Youth.
Tebbe, E.A., Budge, S.L. (2022). Factors that drive mental health disparities and promote well-being in transgender and nonbinary people. Nat Rev Psychol.
Tankersley, A.P., Grafsky, E.L., Dike, J. et al. (2021). Risk and Resilience Factors for Mental Health among Transgender and Gender Nonconforming (TGNC) Youth: A Systematic Review. Clin Child Fam Psychol Rev 24, 183–206
Warrier, V., Greenberg, D.M., Weir, E. et al. (2020). Elevated rates of autism, other neurodevelopmental and psychiatric diagnoses, and autistic traits in transgender and gender-diverse individuals. Nat Commun 11, 3959