Voice and Mental Health Support for Trans Teens and Their Parents: A Workshop Model

Abstract

Providing parents and their teenage children with an opportunity to experience voice modification techniques and discussions about mental health issues could alleviate some of their tremendous minority stress. Speech-language pathologists and counselors can use experiential learning and a multidimensional family approach to support parents and their trans teenagers to build connections and learn individual perspectives on their personal phases of transitioning. Participants of the 3-hour webinar included nine dyads of parents and youths across the United States. Topics on voice modification and mental health strategies were presented. Only parents completed the pre- and post-surveys to measure confidence in their knowledge to support their youth's voice and mental health needs. There were 10 Likert scale questions (5 voice, 5 mental health). The Kruskal–Wallis H-test results revealed that the median responses to the pre and post voice survey did not show a statistically significant change (H = 8.0, p = 0.342). Similarly, the mental health surveys did not reach significance (H = 8.0, p = 0.433). However, the growth trend shows strong promise for developing effective future experiential training workshops as a viable service provision for increasing parents' knowledge in supporting their trans child's voice and mental health needs.

 

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Keywords

Transgender youth - voice training and mental health - experiential learning - mental health - parent support

Learning Outcomes: As a result of this activity, the reader will be able to:

• Describe an interactive experiential learning model for transgender youths and their parents.

• List five types of minority stressors that contribute to youths' suicidality.

• Compare and contrast the transition process for parents and their transgender youth.

Transgender Teenagers in the United States

There is a growing need for service provisions for the expanding transgender youth population. The UCLA Williams Institute School of Law conducted a study to estimate the number of adults and youths who identify as transgender in the United States, and found 1.3 million adults (18 and older) and about 300,000 youths (13–17 years old) who identify as transgender (Herman 2022). The distribution of the transgender population among adults is evenly apportioned throughout the country. This is not the case for transgender youths. Approximately one-third live in the southern states, with the highest population in Texas, with estimates of 29,800 ∼10% of transgender youths (Herman 2022). The service provisions in Texas for transgender youths have recently been scrutinized by lawmakers. According to the Texas Tribune article on 02/28/22, Governor Greg Abbott ordered state child welfare officials to launch child abuse investigations into reports of transgender kids receiving gender-affirming care (Sneha 2022). This type of governmental subversion adds to identity-based stressors defined as prejudice, stigma, discrimination, rejection, bullying, and other forms of violence that may contribute to an elevated mental health risk outcome among trans youth and young adults (Hendricks & Testa 2012).

The growth in the transgender youth population has more likely increased the population of parents impacted by minority (identity-based) stressors. Parents also sustain negative psychosocial problems resulting from minority stressors. These include difficult feelings (e.g., loss, guilt, anger, low libido) and social isolation (Hidalgo & Chen 2019). Parents report these problems negatively affected activities of daily living, low energy, substance abuse, and difficulty maintaining self-care behaviors (Hidalgo & Chen 2019). No studies were found that examines the rate of depression or suicide in parents of transgender youths.

 

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Suicide and Minority Stress

The lifetime suicide attempt rate of trans people is nearly nine times greater than the general US population (4.6%) (Nock & Kessler 2006). The data from the US Transgender Survey indicate that 82% of transgender individuals have considered killing themselves and 40% have attempted suicide (James et al. 2016). Reports suggest that upward of 40% of all trans individuals who have considered or attempted suicide are trans youth or young adults (Bauer et al. 2015). Empirical research has demonstrated associations between minority stressors and suicidality among transgender youth (Veale et al. 2017) and adults (Testa et al. 2017).

Transgender people are subjected to alarming high rates of minority stress such as discrimination, violence, and rejection related to their gender identity or expression (Hendricks & Testa 2012). According to Meyer (1995), minority stress sustained by LGB people are experienced in three processes. The first are the environmental or external events that occur in the individual's life. Examples include discrimination and threats to the individual's safety and security. The second set of processes is the anticipation and expectation that the individual's external stressful event will occur, and they must maintain vigilant because of the expectation. The third process includes negative attitudes and prejudices from society that are internalized, resulting in the most proximal of the three processes. For trans people, the internalized stigma of transphobia is more subjective, not directly observable, but potentially the most damaging due to direct negative effects on the individual's ability to cope with external stressful events and ultimately reduces their resilience (Hendricks & Testa 2012).

Anxiety and depression rates in the United States are reported to be two to six times higher in trans and gender diverse individuals (Bockting et al. 2013; Harvard Medical School 2007). Gender minority groups are disproportionately affected by social stress due to their minority status in society (Hunter et al. 2021). The experiences include proximal stressors which are factors that take place on a personal/individual level (internalized stigma) and distal stressors, facets at the societal level, such as discrimination (Mongelli et al. 2019). Distal minority stressors have been found to be a predictor of suicide attempts and proximal minority stressor a predictor of depressive symptoms in American trans and gender diverse adults (Brennan et al. 2017) and young people (Chavanduka et al. 2021). Chodzen et al (2019) found that high levels of internalized transphobia were associated with higher depression and anxiety in American trans and gender diverse young people (Hunter et al. 2021).

 

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Stressors and Resilience Factors

A study conducted by Austin et al. 2022, examined the influence of interpersonal and environmental microaggressions, internalized self-stigma, and adverse childhood experiences (ACEs), and protective factors such as school belonging, family support, and peer support on lifetime suicide attempts and past 6-month suicidality in 372 trans youths (Hendricks & Testa 2012). Of the transgender youth in the sample, 56% have reported a previous suicide attempt and 86% of the sample reported suicidal ideation within the past 6 months of the study (Hendricks & Testa 2012). Interpersonal microaggressions, such as receiving daily negative messages that target youth's marginalized identity, revealed a significant contribution to lifetime suicide attempt (Hendricks & Testa 2012). Individuals subject to emotional neglect within the family were 2.5 times more likely to report a lifetime of suicide attempt, consistent with general population studies that have established this link (Hendricks & Testa 2012). Emotional neglect may be related to or experienced as rejection of not belonging in one's family (Hendricks & Testa 2012).

Microaggressions have been defined as brief, commonplace, daily verbal, behavioral, or environmental indignities, whether intentional or unintentional, that communicate hostile, derogatory, insults toward marginalized and minoritized people (Hunter et al. 2021). While microaggressions have significantly harmed our transgender youths, they are often ambiguous. Targeted individuals and perpetrators alike may dismiss or minimize their potential harm (Fisher et al. 2019; Munro et al. 2019). When challenged, perpetrators often attempt to explain their comments and/or actions as a joke or misunderstanding (Fisher et al. 2019), thus making microaggressive behaviors (implicit or explicit) difficult to prove.

A study conducted by Gartner and Sterzing (2018) found that interpersonal microaggressions contributed to lifetime suicidal attempts and emotional neglect by family. Trans youths' feelings of school belonging, emotional neglect by family, and internalized self-stigma significantly contributed to attempts of suicide in the past 6 months of their study. At the family level, higher levels of child maltreatment and family religiosity were significantly associated with more frequent interpersonal microaggressions (Gartner & Sterzing 2018). Microaggressions leave our transgender youths feeling isolated, neglected, and alone with no one to protect them or talk to (Gartner & Sterzing 2018; Schwartz et al. 2012).

Microaggressions impact the youths and parents very differently. However, the high influence that microaggression has on suicidality among transgender youth and the negative psychosocial effects on parents' mental health bolsters the need for increased service provisions targeting open discussions between parents and youths on similar struggles in their journey toward transition.

 

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Parent Perspective and Role

There are very few service provisions for collaborative experiential learning between transgender youth and their parents. Voice-affirming services for transgender youths are typically conducted in private, individual sessions. Parents wait for the session to end, hoping to gain a view of their youth's experiences, yearning to be more involved than just their youth's ride to therapy. The role of parents in early adolescence is viewed to have more knowledge and social power, and assume the role of providing security and warmth (Branje 2018). This appears to be the role parents take during the initial stages of their youth's transition. However, as adolescents develop, there is an expectation of parents taking on a more equal, symmetrical, and reciprocal interactive role (Branje 2018). Parents may not be ready for this stage perhaps until they learn more about the changes occurring in their youth. Moreover, while youths ponder on when to come out to their parents, months or perhaps years go by before their parents are informed of their gender identity. For parents, the transition may be challenging for them to accept (Pullen Sansfaçon et al. 2021; Pullen Sansfaçon et al. 2022). A qualitative study conducted by Andrzejewski et al (2021) on transgender youths' perspective on parental support reported that while parents provide support accessing health care by helping youths with logistical support such as finding providers and attend appointments, parents were not always supportive of medical gender-affirmation services, such as initiation of gender-affirming hormones that would have reduced the youth's feelings of dysphoria.

A study conducted by Pullen Sansfaçon et al. (2021) shows that parents may struggle to accept their child's identity during transition and beyond, rendering this life stage particularly challenging for both parents and trans as well as nonbinary youths. Although parental support is key, parents may encounter many challenges in adapting to the new reality and the adaptation process is often long (Pullen Sansfaçon et al. 2020; Pullen Sansfaçon et al. 2021). Parents can experience grief and a sense of loss (Aramburu Alegría 2018; Coolhart et al. 2018; Pullen Sansfaçon et al. 2020; Pullen Sansfaçon et al. 2022; Wahlig 2015) denial, disbelief, or anger (Aramburu Alegría 2018; Pullen Sansfaçon et al. 2020; Pullen Sansfaçon et al. 2022; Wahlig 2015). Parents are often concerned about the safety and acceptance of their child by others (Aramburu Alegría 2018; Lawlis et al. 2017; Pullen Sansfaçon et al. 2015; Pullen Sansfaçon et al. 2022; Wahlig 2015) and they may feel powerless (Pullen Sansfaçon et al. 2015; Pullen Sansfaçon et al. 2022) and socially judged or isolated (Pullen Sansfaçon et al. 2015; Pullen Sansfaçon et al. 2022; Wahlig 2015).

 

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Interventions for Parents

Several elements have been shown to help parents overcome these challenges and move toward acceptance: becoming educated about trans issues (Pullen Sansfaçon et al. 2020; Pullen Sansfaçon et al. 2022; Wong & Drake 2017), knowing they can protect their child from the negative repercussions of discrimination, and helping to promote their child's happiness (Coolhart et al. 2018; Pullen Sansfaçon et al. 2022), and being proactive in the child's transition by accompanying them or advocating for them (Birnkrant & Przeworski 2017; Pullen Sansfaçon et al. 2022). Having professional and peer support has also been shown to be very helpful in this acceptance journey (Aramburu Alegría 2018; Pullen Sansfaçon et al. 2015; Pullen Sansfaçon et al. 2020; Pullen Sansfaçon et al. 2022). Validating the parents' journey through their youth's transition could lead to a better understanding of the parents' timeline toward their path to acceptance (Shpigel et al. 2015). An open dialogue could promote a safe experience to establish support for each other's journey.

According to Malpas (2011), interventions with parents emphasize adjustment to the social difference of the child and promote restoration and flourishing of the parent–child bond. Focus is also placed on self-help, peer-advocacy, and education of larger social institutions (Boenke 1999; Greytak et al. 2009; Mallon 2009; Malpas 2011). There are multiple studies that support parental inclusion to be valuable for transgender youths' transition. Parents provide encouragement, resources, advocacy, mental, and emotional support (Branje 2018). Offering parents an indirect view of their youth's transition could provide more knowledge to satisfy their need to support their youth with security and warmth. The development of this experiential model could contribute toward a more equal and reciprocal interaction for positive mental and emotional well-being for them (Fumero et al. 2021; Heck et al. 2015).

The piloted training workshop for parents to experience voice modification exercises provides a service provision model to gain a perspective of their youth's challenges and offer a sense of dignity to undergo therapy with autonomy and trust. The experiential learning workshop with parents and their trans youth together has the potential to increase the knowledge of the other's perspective during the transition of both groups. The workshop was designed to allow parents to experience exercises used during voice modification therapy, and to engage in discussions about microaggressions that trans youths often experience. The workshop also aimed to discuss the parents' challenges during their teenager's social transition. Service provisions that offer a guided platform to express the stressors that impact each other's life could improve empathy and mutual understanding. This model of service is supported by standards of care issued by the World Professional Association for Transgender Health (WPATH) in which a multidisciplinary approach to assessment and treatment is recommended (Coleman et al. 2022).

 

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Multidimensional Family Approach Model

The multidimensional family approach (MDFA) model for affirming youths and parents helps to develop a “both/and” stance for protection and acceptance, adaptation, and nurturing (Malpas 2011). This model allows clinicians the ability to move flexibly between multiple roles. The components of the MDFA include (1) parental engagement and education, (2) individual assessment and youth therapy, (3) parental coaching, (4) systemic family therapy, and (5) parent support group (Malpas 2011). This model allows for an interprofessional collaboration structure where the speech-language pathologist could take the role of educating and engaging parents on voice and communication strategies involved in transgender voice care. A counselor could provide individual mental-health assessment and youth therapy. An experienced parent could lead a parent support group. A social worker and/or speech-language pathologist could take the role of parental coaching, and a psychologist could provide systemic family therapy (Malpas 2011). Clinicians informed by the multimodal MDFA may employ parental psychoeducation and coaching as they help parents build gender-affirming capacity in their family systems (Malpas 2011). Psychoeducation can be provided on topics related to gender development, research findings on pediatric gender dysphoria, and the critical role of parents in providing nurturance, affirmation, and advocacy (Malpas 2011). The aim is to empower parents as resources and decision makers in issues affecting their child's well-being (Hidalgo & Chen 2019; lgbtmap 2019). For transgender youth, the MDFA aims to create a space where they can be seen more completely (Corbett 2009; Munro et al. 2019). It could also include conversations on their comfort in school and potential instances of bullying and teasing that were experienced recently or throughout their family and education history (Hidalgo & Chen 2019).

The experiential learning model used in the current workshop operates as an appendage of the MDFA model. It could extend from the sections of parental engagement and education, and parent coaching by experiencing voice and communication therapy. Additionally, the experiential learning workshop compliments the MDFA's element of family therapy through open discussions on microaggressions from the viewpoint of the parent and their transgender youth (Hidalgo & Chen 2019; Malpas 2011; Munro et al. 2019).

 

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Methods

Participants

In this IRB-approved study, participants of the workshop were recruited through a dissemination of a flyer that was posted in transgender community social media sites. The flyer contained the title of the free workshop, the target audience for the workshop (parents and youths: 12–17 years), the event time and date, the length of the workshop, a general description of activities, names of presenters, and a link to a Google form to RSVP. The Zoom link for the webinar was disclosed only to parents who submitted an RSVP. Parents were required to report that they were 18 years or older and that their children were between 12 and 17 years old. No demographic data were obtained. There were nine parent and youth dyads recruited for the study nationwide from Antelope Valley, CA, to Atlanta, GA. While the initial format of the workshop was to provide free in-person learning experiences for dyads of parent–youth groups, the workshop required a shift to a virtual offering prompted by the nationwide COVID closure restrictions. This delayed the workshop by 2 weeks and limited the number of participants from 30 dyads attending in-person to nine dyads virtually. Although the virtual platform restricted the number of participants, it expanded the region of recruited participants. The wider reach of participants could have valuable implications for future provisions in offering these types of workshops through a virtual platform.

 

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Workshop Protocol

Parents and youths attended the same workshop online. A 3-hour time ordered agenda of the workshop composed of a 20-minute introduction and completion of the parent pre-workshop surveys: 70 minutes of mental health presentation followed by a 10-minute break. Voice and communication information was covered in the next 70-minute presentation. The final 10 minutes was left for Q&A and completion of post-workshop parent surveys in voice and mental health. The pre- and post-surveys were obtained through a link to a Google form.

 

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Mental Health and Voice and Communication Presentation

Information on mental health focused on clarifying terminology and strategies to implement in topics such as transgender 101, microaggression, intersections, mental health, and affirming parenting strategies. The voice and communication presentation highlighted topics on vocal health, basic anatomy and physiology of the vocal mechanism, mindfulness, pitch, stress and intonation, resonance, intensity, nonverbal gestures, verbal communication, and the relationship between mental health and voice. Youths and parents were invited to participate in voice exercises, pitch matching, resonance simulation, and stress and intonation. The topic titles and presentation details are outlined in [Table 1].

Table 1 Mental health and voice and communication presentation agenda

Topic title	Presentation details
20-min introduction and pre-workshop surveys	Presenter introductions and time for parents to complete pre-workshop surveys
70-min mental health presentation
Transgender 101	Clarification on definitions of biological sex, gender identity, gender expression, and sexual orientation. Discussions on what it means “to transition” included self-discovery, coming out, accessing medical care, legal changes in name and driver's license, and Arizona's policies on how to change gender markers on their birth certificate
Microaggression	Definitions of microassaults, microinsults, and microinvalidations. Participants engaged in an activity to examine passive, aggressive, and assertive communication styles and how they contribute to microaggressive behaviors. The presentation continued with minority stress model, providing examples of distal and proximal stressors
Intersections	Addressed how gender identity and expression disparities are further compounded by race, class, income, wealth (available resources), citizenship status, education, geographic location, and age
Mental health	Defining markers of depression, anxiety, and suicide, in addition to how to support someone with suicidal ideation and signs that require immediate help, ongoing support, and available resources. Adverse childhood experiences and the major risk factors that lead to illness, poor quality of life, and death were also included in this section
Affirming parenting strategies	How to create supportive environments, require respect among family, express love and support, zero tolerance, communication, differences between acceptance and support, mirror language, and education
Closing discussion	Discussion on co-regulating strategies as a method for providing assistance and support of optimal self-regulation through warm and responsive interactions
10-min break
70-min voice and communication presentation
Vocal health	The do's and don'ts of caring for their voice. Importance of hydration, avoiding use and exposure to environments where smoking or vaping occur, definitions of phonotraumatic behaviors such as yelling, screaming, prolong use of inappropriate pitch, and obtain adequate sleep and vocal rest
Basic anatomy and physiology of the vocal mechanism	Participants learned that voice is created with breath. They were taught “belly breathing” strategies to maximize breath support. An activity to measure maximum phonation time by using “belly breathing” was introduced. Parents and youths were asked to use their phones to time how long they can phonate an /a/. They were instructed to place their hand on their belly and feel it expand while they take in a breath. As they exhaled, they were asked to say /a/ for as long as they could while they timed themselves. They were provided with normative measures of maximum phonation time for cis females and cis males. A digital photograph of the vocal folds identifying basic structures was presented. Information on what happens to the vocal folds when we use low and high pitch and when we speak was discussed. This was followed by a video of the vocal folds performing various speech sounds
Mindfulness	Mindfulness as an element of sustaining voice modification techniques was discussed. A relaxation exercise that incorporated mindful breathing was practiced. There was basic information shared on pitch range differences between cis female, trans female, cis male, and trans male and how to incorporate mindfulness strategies when reaching a desired pitch
Pitch	Brief demonstration on acoustic assessment was conducted. Using SonaSpeech, we demonstrated how acoustic measures are obtained and used as a screening tool to detect the need for a visual exam of the vocal folds. It was emphasized how the initial exam is important in gathering baseline data, learning about their goals and history, and the possible need for further physician evaluation. This was followed by incorporating a pitch matching activity by beginning at a comfortable pitch and moving up one semitone at a time, stopping within the range of their self-identified pitch. Participants explored their self-identified pitch by humming, phonating a vowel, producing a syllable, and counting 1–5
Stress and intonation	A discussion on how pitch changes occur when we add stress and intonation to our speech with various rising and falling patterns. Participants were given a stress and intonation activity where they emphasized different words of one sentence. Next, information on gender differences in intonation where females intone upward and have a larger semi-tone range, whereas masculine intonation characterized by downward inflection was shared (Hancock & Siegfriedt 2019). The walk, jump, step, fall (WJST) strategy by Adler et al. (2018) was introduced as a standard intonation pattern for many phrases in American English
Resonance and intensity	This topic was followed with a discussion on the gender differences in resonance. Forward resonance strategies were incorporated with self-identified feminine pitch and breath support. The participants engaged in an activity to hum at their self-identified pitch and feel the vibrations around their lips and face and sense the forward resonance of their sound. For masculine resonance, the participants were asked to phonate a back vowel /a/ and /o/ at the male pitch range while increasing the opening of their oral cavity and dropping their jaw (Mills & Stoneham 2017). They were instructed to feel sound vibrations in their chest. There was a brief discussion on intensity differences between male (louder) and female (softer) genders
Nonverbal communication and relationship between mental health and voice	The presentation segued to a discussion on the gender differences in nonverbal communication followed by how voice and communication modification contributes to mental health wellness
10-min Q&A, parent post-workshop surveys, and closing remarks	The presentation concluded with a review of the various topics discussed, Q&A, and a completion of post-survey parent questionnaire. The presenters also emailed participants' resources on mental and vocal health strategies, gender support plan, and referral list of SLPs providing gender-affirming services throughout the country

 

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Measures

The survey administered to parents before and after the workshop included 5-point Likert scale to self-rate their knowledge on five questions on voice and communication strategies for their child and to self-rate their knowledge on five questions on tools to increase and sustain their child's mental and emotional health. Additionally, one Likert scale question on the effectiveness of the workshop's structure was included in the post-workshop survey. All Likert scales were 1 to 5, where 1 represented “very low” and 5 represented “very high.” Points 2, 3, and 4 were not explicitly defined. On the pre-workshop survey, participants reported what they hoped to learn, their expectations of the workshop, and current knowledge on strategies to create a safe space, whereas the post-workshop survey queried what the participants learned, wished they learned, the effectiveness of the workshop structure, and whether they had increased knowledge on creating a safe space. The survey questions are reported in [Figs. 1] and [2]. There were opened-ended questions such as: “A question I hope to have answered from the workshop is…,” “My biggest take-away from this workshop is ….” The responses to the qualitative questions were not included in the analysis. Participants were given 10 minutes to complete the surveys.

 

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Results

Change in Self-Ratings of Knowledge in Voice

The Kruskal–Wallis H-test was utilized to measure nonparametric values obtained from a 5-point Likert scale survey of pre and post knowledge of voice and communication development. Nine parents responded to five pre and five post survey questions for a total of 90 survey responses. The Kruskal–Wallis H-test was performed to determine if the median responses were the same across surveys. The results revealed that there was no significant difference in the median responses between pre and post voice surveys, with a Kruskal–Wallis H-test = 8.0 and a p-value = 0.342. [Table 2] reports the results of the analysis from the nine participants who completed the surveys. The results of chi-square values, Kruskal–Wallis H-test, degrees of freedom, and p-values for the voice and mental health groups are illustrated in [Figs. 1] and [2], respectively. The median for the pre voice surveys increased by 1 to 2 points in the post surveys ([Fig. 1]). The results suggest that the participants attended the workshop with less knowledge about voice and communication development than after the presentation.

Figure 1 Box results of voice pre and post surveys. Note: V1 = knowledge about talking to my child regarding transition, V2 = knowledge of the voice and communication changes occurring during my child's transition, V3 = knowledge to support my child's voice and communication changes, V4 = knowledge of resources available to support my child's voice and communication needs, V5 = knowledge of the different voice and communication needs between trans male and trans female individuals.

Figure 2 Box results of mental health pre and post surveys. Note: MH1 = possess strategies needed to support my child in their emotional health during their transition; MH2 = understand the difference between gender expression and gender identity; MH3 = knowledge about different types of microaggressions; MH4 = potential mental and physical health risks associated with prolonged exposure to microaggressions, social stigma, and minority stress; MH5 = recognize five signs of depression and/or suicidal thoughts.

Table 2 Results of survey analysis

	Voice survey results	Mental health survey results
N	9	9
Chi-square	9.000b	9.000b
Kruskal–Wallis H	8.00	8.00
df	8	8
p-Value	0.342	0.433

 

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Mental Health

The nine parent participants also completed the mental health surveys. The results of the Kruskal–Wallis H-test revealed a score of 8.0 and a p-value of 0.433. Similar to the results of the voice surveys, the distribution of participants' responses across the mental health survey questions revealed no significant difference (see [Table 2]). The calculated median between pre and post mental health responses showed very little gain in knowledge from pre to post results (see [Fig. 2]). [Fig. 2] also shows a higher mental health median prior to the presentation when compared to pre-voice and communication median in [Fig. 1].

 

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Effectiveness of the Workshop Structure

All parent participants answered one question on the effectiveness of the workshop's structure. Their responses were either a Likert score of 4 or 5. The calculated mean equaled 4.444 with a standard deviation of 0.563.

 

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Participants' Report on Workshop Expectations and Suggested Future Topics

Prior to the workshop, participants reported their expectations to gain more overall knowledge in voice and mental health, strategies to help their teen, resources that they can refer to, technology for voice, and strategies to balance support and their youth's ability to be independent and strong. The participants also reported using strategies to create an affirming, supportive, and safe home environment such as connecting with mental health providers, using their youth's chosen name and their pronouns, and participating in LGBTQI support and social groups.

After the workshop, there was still a general need for online parent groups, community support, and resources. Specific needs in voice include strategies for having voice services covered by insurance, a directory of speech providers in their area, more strategies to increase pitch, and information on how much voice can be trained to sound more feminine or masculine. In the domain of mental health, there was the need for strategies to help their youth express their emotions, empower trans youths to transition into adulthood, assist with self-regulation, support their youth while holding them accountable for responsibilities, and resources on unintentional unsupportive interaction. Some participants provided suggestions on how to change the workshop structure. They proposed having more detailed voice training and techniques, shorter multiple workshops with concise information to prevent overload and stress/anxiety, less trans basic information, and more interactivity and in-person workshop post-COVID.

 

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Discussion

Strategies to support voice modification, emotional health, microaggressions, mental and physical health risks, signs of depression, and/or suicidal thoughts were among the factors measured through parents pre and post surveys. Additional survey questions could be added to measure more specific areas of growth.

The median scores of the pre to post voice survey results indicate that the parent participants' knowledge of measured voice and communication information increased with information presented at the workshop, thus supporting the workshop as a viable service provision for parents and transgender youths. The high median scores of the pre-mental health survey indicate that the participants attended the workshop with prior knowledge of basic mental health information affecting this population. While the growth of knowledge from before and after the mental health presentation was not significant, a positive increase continues to support the viability of the structure of this workshop. The results of the survey question on the effectiveness of the workshop's structure add strong support to the efficacy of the interprofessional model, the experiential and collaborative learning structure for parents and youths, and the virtual platform of the workshop presentation. The participants' expectations and suggestion for future topics have provided the presenters with ideas on modifying the structure of the workshop and content with more detail and thorough information. The collective results give support to create an experiential learning workshop that is interprofessional, with more detailed techniques and strategies, and in-person and/or virtual offerings.

The data analysis points to varying degrees of knowledge and the need to adjust the presentations to meet the specific audience's level of understanding. The limited data collected in the study support the need for more studies on experiential learning workshops for parents and transgender youths. A comparative study on an in-person and online workshop design could reveal different models of the workshop platforms, and create programs that extend to populations that are out of reach for in-person types of services. These experiential workshop designs are beneficial for community clinicians to create evidence-based models for collaborative offering to support their transgender clients and their parents.

Future Directions

There is need for more detailed and complex level of instruction in voice and mental health information. Incorporating aspects of the MDFA model (e.g., parent education and parent support group) in this type of workshop addresses the need for this program as revealed in this study. The comparative results, though small in size, revealed an increase in knowledge in both areas of voice and mental health. Understanding the possible levels of participants and preparing to adjust the content of the workshop could improve the outcomes for increase knowledge of information. This workshop could also provide a curriculum model for online high schools to educate parents and transgender youths on transitioning support. Incorporating programs with this design in public online schools could mitigate the cost of transgender youth voice and mental health services and provide access for parents and transgender youths support.

 

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Limitations

Adolescent surveys were not obtained due to time constraints for adaptations required to the IRB as a result of COVID closures. COVID closures also required a shift from in-person to virtual. In-person registration was higher than online offering. The timeline to recruit online participants was 2 weeks versus 4 to 6 weeks for in-person participants. This limited our participants from 30 registered parent and youth dyads to 9. While we were not able to survey the youths who attended the workshop, their feedback would be valuable for gauging their understanding or empathy toward their parents' emotional development of the transition process.

 

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Conclusion

A 3-hour workshop given by collaborating SLP and mental health practitioners is a viable service provision that benefits parents and their transgender youth. The parent participants gained knowledge of voice and communication strategies and mental health methods to support their transgender youth.

 

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Conflict of Interest

None declared.

Acknowledgements

We would like to thank Dr. Shelley Gray who was generous in offering her time and guidance. Our families and many colleagues who have encouraged our work, thank you for your unyielding support. We are grateful to the participants who joined us in this virtual workshop during the COVID lockdown.

Disclosures

M.S. is a clinical associate professor and an employee of Arizona State University. She has no financial or nonfinancial interest in the subject matter or materials discussed in this manuscript.

R.J.R. is a Ph.D. student at Arizona State University. He has no financial or nonfinancial interest in the subject matter or materials discussed in this manuscript.

J.S. is a counselor in private practice. He has no financial or nonfinancial interest in the subject matter or materials discussed in this manuscript.

• References

• Adler, R. K., Hirsch, S., & Pickering J. (2018). Voice and Communication Therapy for Transgender/Gender Diverse Client: A Comprehensive Clinical Guide. Plural Publishing
• Andrzejewski, J., Pampati, S., Steiner, R. J., Boyce, L., & Johns, M. M. (2021). Perspectives of transgender youth on parental support: qualitative findings from the Resilience and Transgender Youth Study. Health Education & Behavior, 48(1), 74–81
• Aramburu Alegría, C. (2018). Supporting families of transgender children/youth: parents speak on their experiences, identity, and views. International Journal of Transgenderism, 19(2), 132–143
• Austin, A., Craig, S. L., D'Souza, S., & McInroy, L. B. (2022). Suicidality among transgender youth: elucidating the role of interpersonal risk factors. Journal of Interpersonal Violence, 37(5-6), NP2696–NP2718
• Bauer, G. R., Scheim, A. I., Pyne, J., Travers, R., & Hammond, R. (2015). Intervenable factors associated with suicide risk in transgender persons: a respondent driven sampling study in Ontario, Canada. BMC Public Health, 15, 525
• Birnkrant, J. M., & Przeworski, A. (2017). Communication, advocacy, and acceptance among support-seeking parents of transgender youth. Journal of Gay & Lesbian Mental Health, 21(2), 132–153
• Bockting, W. O., Miner, M. H., Swinburne Romine, R. E., Hamilton, A., & Coleman E. (2013). Stigma, mental health, and resilience in an online sample of the US transgender population. American Journal of Public Health, 103(5), 943–951
• Boenke, M, ed. (1999). Transforming families: Real stories about transgendered loved ones. Imperial Beach, CA: Walter Trook Publishing
• Branje, S. (2018). Development of parent-adolescent relationships: conflict interactions as a mechanism of change. 10.1111/cdep.12278
• Brennan, S. L., Irwin, J., Drincic, A., Amoura, N. J., Randall, A., & Smith-Sallans M. (2017). Relationship among gender-related stress, resilience factors, and mental health in a Midwestern U.S. transgender and gender-nonconforming population. International Journal of Transgenderism, 18(4), 433–445
• Chavanduka, T. M. D., Gamarel, K. E., Todd, K. P., & Stephenson, R. (2021). Responses to the gender minority stress and resilience scales among transgender and nonbinary youth. Journal of LGBT Youth, 18(2), 135–154
• Chodzen, G., Hidalgo, M. A., Chen, D., & Garofalo, R. (2019). Minority stress factors associated with depression and anxiety among transgender and gender-nonconforming youth. Journal of Adolescent Health, 64(4), 467–471
• Coleman, E., Radix, A. E., Bouman, W. P., et al. (2022). Standards of care for the health of transgender and gender diverse people, version 8. International Journal of Transgender Health, 23(Suppl 1), S1–S259
• Coolhart, D., Ritenour, K., & Grodzinski, A. (2018). Experiences of ambiguous loss for parents of transgender male youth: a phenomenological exploration. Contemporary Family Therapy, 40(1), 28–41
• Corbett, K. (2009). Boyhoods: Rethinking Masculinities. New Haven: Yale University Press
• Fisher, C. M., Woodford, M. R., Gartner, R. E., Sterzing, P. R., & Victor, B. G. (2019). Advancing research on LGBTQ microaggressions: a psychometric scoping review of measures. Journal of Homosexuality, 66(10), 1345–1379
• Fumero, K., Torres-Chavarro, M., & Wood, C. (2021). Challenges in service provision to children and families from linguistically diverse backgrounds. Seminars in Speech and Language, 42(5), 395–418
• Gartner, R. E., & Sterzing, P. R. (2018). Social ecological correlates of family-level interpersonal and environmental microaggressions toward sexual and gender minority adolescents. Journal of Family Violence, 33(1), 1–16
• Greytak, E. A., Kosciw, J. G., & Diaz, E. M. (2009). Harsh realities: The experiences of transgender youth in our nation's schools. Accessed April 15, 2011 at: http://www.glsen.org/binary-data/GLSEN_Attachments/file/000/001/1375-1.pdf
• Hancock, A. B., & Siegfriedt, L. L. (2019). Transforming Voice and communication with transgender and gender-diverse people: An evidence-based process. Plural Publishing
• Harvard Medical School. (2007). National comorbidity survey (NCS). Accessed January 20, 2023 at: https://www.hcp.med. harvard.edu/ncs/index.php
• Heck, N. C., Croot, L. C., & Robohm, J. S. (2015). Piloting a psychotherapy group for transgender clients: description and clinical considerations for practitioners. Professional Psychology, Research and Practice, 46(1), 30–36
• Hendricks, M. L., & Testa, R. J. (2012). A conceptual framework for clinical work with transgender and gender nonconforming clients: an adaptation of the Minority Stress Model. Professional Psychology: Research and Practice, 43(5), 460–467
• Hidalgo, M. A., & Chen, D. (2019). Experiences of gender minority stress in cisgender parents of transgender/gender-expansive prepubertal children: a qualitative study. Journal of Family Issues, 40(7), 865–886
• Hunter, J., Butler, C., & Cooper, K. (2021). Gender minority stress in trans and gender diverse adolescents and young people. Clinical Child Psychology and Psychiatry, 26(4), 1182–1195
• James, S. E., Herman, J. L., Rankin, S., Keisling, M., Mottet, L., & Anafi, M. (2016). The Report of the 2015 U.S. Transgender Survey. Washington, DC: National Center for Transgender Equality
• Lawlis, S. M., Donkin, H. R., Bates, J. R., Britto, M. T., & Conard, L. A. E. (2017). Health concerns of transgender and gender nonconforming youth and their parents upon presentation to a transgender clinic. Journal of Adolescent Health, 61(5), 642–648
• Mallon, GP. (2009). Social Work Practice with Transgender and Gender Variant Youth (2nd ed.). New York: Routledge
• Malpas, J. (2011). Between pink and blue: a multi-dimensional family approach to gender nonconforming children and their families. Family Process, 50(4), 453–470
• Meyer, I. H. (1995). Minority stress and mental health in gay men. Journal of Health and Social Behavior, 36(1), 38–56
• Mills, M., & Stoneham, G. (2017). The Voice Book for Trans and Non-binary People: A Practical Guide to Creating and Sustaining Authentic Voice and Communication. Kingsley Publishers
• Mongelli, F., Perrone, D., Balducci, J, et al. (2019). Minority stress and mental health among LGBT populations: an update on the evidence. Minerva Psichiatrica, 60(1), 27–50
• Munro, L., Travers, R., & Woodford, M. R. (2019). Overlooked and invisible: everyday experiences of microaggressions for LGBTQ adolescents. Journal of Homosexuality, 66(10), 1439–1471
• Nock, M. K., & Kessler, R. C. (2006). Prevalence of and risk factors for suicide attempts versus suicide gestures: analysis of the National Comorbidity Survey. Journal of Abnormal Psychology, 115(3), 616–623
• Pullen Sansfaçon, A., Kirichenko, V., Holmes, C., et al. (2020). Parents' journeys to acceptance and support of gender-diverse and trans children and youth. Journal of Family Issues, 41(8), 1214–1236
• Pullen Sansfaçon, A., Robichaud, M. J., & Dumais-Michaud, A. A. (2015). The experience of parents who support their children's gender variance. Journal of LGBT Youth, 12(1), 39–63
• Pullen Sansfaçon, A., Gelly, M. A., & Ens Manning, K. (2021). Affirmation and safety: an intersectional analysis of trans and nonbinary youths in Quebec. Social Work Research, 45(3), 207–219
• Pullen Sansfaçon, A., Medico, D., Gelly, M., Kirichenko, V., & Suerich-Gulick, F. (2022). Blossoming child, mourning parent: a qualitative study of trans children and their parents navigating transition. Journal of Child and Family Studies, 31(7), 1771–1784
• Schwartz, S. E. O., Lowe, S. R., & Rhodes, J. E. (2012). Mentoring relationships and adolescent self-esteem. The Prevention Researcher, 19(2):17–20
• Shpigel, M. S., Belsky, Y., & Diamond, G. M. (2015). Clinical work with non-accepting parents of sexual minority children: addressing causal and controllability attributions. Professional Psychology, Research and Practice, 46(1), 46–54
• Sneha D. (2022). Texas' child welfare agency told staffers to keep quiet about gender-affirming care investigations, documents show. The Texas Tribune. February 28, 2022
• Testa, R. J., Michaels, M. S., Bliss, W., Rogers, M. L., Balsam, K. F., & Joiner, T. (2017). Suicidal ideation in transgender people: gender minority stress and interpersonal theory factors. Journal of Abnormal Psychology, 126(1), 125–136
• thisisloyal.com. Herman JL. Williams Institute. Accessed October 24, 2022 at: https://williamsinstitute.law.ucla.edu/experts/jody-l-herman/. Published September 12, 2022
• Veale, J. F., Peter, T., Travers, R., & Saewyc, E. M. (2017). Enacted stigma, mental health, and protective factors among transgender youth in Canada. Transgend Health, 2(1), 207–216
• Wahlig, J. L. (2015). Losing the child they thought they had: therapeutic suggestions for an ambiguous loss perspective with parents of a transgender child. Journal of GLBT Family Studies, 11(4), 305–326
• Wong, W., & Drake, S. J. (2017). A qualitative study of transgender children with early social transition: parent perspectives and clinical implications. PEOPLE: International Journal of Social Sciences, 3(2), 1970–1985
• Talking about Family Acceptance and Transgender Youth. Accessed January 25, 2023 at: www.lgbtmap.org/messaging-guides

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Artikel online veröffentlicht:
07. März 2023