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. 

Definitions:
The term “Transgender and Non-Binary” (TNB)is broken down into two distinct parts.  Transgender is an “umbrella term for people whose gender identity and/or expression is different from cultural expectations based on the sex they were assigned at birth” (HRC). Non-binary is a broad term to describe individuals that “experience their gender outside binary conception of gender” (Tebbe & Budge, 2022) or as an umbrella term that may be “encompassing identities such as agender, bigender, genderqueer or gender-fluid” (HRC). These are just some of the terminology used related to how a person may identify themselves, and there is a further glossary of possible terms through the Human Rights Campaign (HRC). Many of these terms may apply to students and/or youth that school psychologists will work with. However, no group is a monolith for which a single set of rules or standards can be applied for, and in all situations practitioners should consider that any broadly defined identity likely will have features or elements that are not all encompassing for each member.

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. 

Population Estimates:
Estimates from limited studies have suggested that 0.1 to 0.5% of the world population may be transgender, which equates to between 7.8 to 38.8 million people (Tebbe & Budge, 2022). It has also previously been estimated that as many as 1 in 200 youth, or 2%, identify as transgender (Johns et al. 2017; Harris & Frader, 2019). Although nonbinary identities have often been grouped under the umbrella term of “transgender”, survey data from the Trevor Project’s 2021 National Survey on LGBTQ Youth Mental Health shows that only 50% of youth who identified as nonbinary also identified as transgender; an additional 20% were not sure or questioning if they were transgender. A recent poll found that 35% of Generation Z (those ages 13 to 21 in 2018) know someone who uses gender-neutral pronouns (Parker et al., 2019). 

Legal and Ethical Implications: 
The NASP Principles for Professional Ethics begin with the quote, “School psychologists engage only in professional practices that maintain the dignity of all with whom they work” (NASP Professional Ethics, 2020, p.42). In order to maintain dignity, there is an implicit need to be sufficiently familiar with relevant information for those we are evaluating in order to “provide culturally responsive and equitable practices in all domains of service delivery for diverse individuals, families, schools, and communities.” NASP has taken a clear stance to support gender diversity, and a person’s right to express, explore, and modify gender identity. According to OSPI, Washington public schools also have a responsibility to provide a safe and nondiscriminatory environment for all students, including transgender and gender-expansive students. The ACLU has also noted in an open letter to school principals and superintendents that students have “the constitutional right to share or withhold information about their sexual orientation or gender identity from their parents, teachers, and other parties, and it is against the law for school officials to disclose, or compel students to disclose, that information”. A recent lawsuit from New Hampshire also addressed a district policy to maintain a student’s privacy related to their gender identity and/or transgender status at the student’s request. The court upheld that the policy did not inhibit a parent’s right to parent, and that the school district maintained the right to not disclose information to parents related to a student’s chosen name and/or pronouns, suggesting there is a continued support for the underlying rights of student’s privacy in the school setting ( Jane Doe v. Manchester School District, 2022). Further ACLU cases have similarly demonstrated that students have the right to be treated consistently with their gender identity at school, and to express their gender at school. 

Foundational Information:
Increased risk factors of mental health disorders for TNB youth have been well-studied, and more information is being gathered about TNB youth and neurodiversity. According to a large study examining the connection between gender identity and autism, transgender and gender-diverse individuals were three times as likely to be autistic than were cisgender individuals, after controlling for age and educational attainment (Warrier et al., 2020). In two of five datasets reviewed through the study, transgender and gender-diverse individuals also had elevated rates of ADHD, OCD, and learning disorders compared to cisgender individuals. It should also be considered that there have been a number of studies that have examined the relationship between TNB youth and mental health related to the possible positive implications of medical interventions (I.E Gender affirming surgeries, hormonal therapy, etc.). While this information should be considered, there have been notes that studies are needed to further examine the magnitude of a potential effect and the longevity. (Tebbe & Budge, 2022).A recent Communiqué article noted transgender and nonbinary youth are beginning to experience a rise in harassment and discrimination at school, and posited that it is the duty of school-based professionals, such as school psychologists, to take action with prevention and intervention (Ryan, 2021). 

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)

Evaluation Considerations:
In the context of conducting evaluations, it is important to remain focused on the referral question and to refrain from pathologizing their gender identity for TGNC youth (Shatila, Kneedler, and Chen 2021). One major consideration is that the scores of many of the rating scales, because the population norms are not inherently inclusive for TNB youth, may not be an accurate measure. A study of the best practice in neuropsychology noted that “Scores of transgender clients may be artificially inflated and may not be indicative of psychopathology, especially if a client is early in the identity formation or gender transition process.” and noted that it may be better to “..consider not using standardized assessments and relying more heavily on the history in light of gender dysphoria, gender minority stress, and gender transition status.” (Keo-Meier & Fitzgerald, 2017). Best practice articles in school psychology have similarly argued that qualitative evaluation methods could be used to provide valuable insight into a student's unique strengths and needs, and that it may be better to prioritize conversations and interviews with students, caregivers, educators, and staff to gain a comprehensive understanding of each student. (Shatila, Kneedler, & Chen 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.

Reflections:
Please note that best practice is an ever evolving target that involves challenging conversations amongst professionals. While the information in this response was collected with thoughtful considerations from many professional entities, as well as joint input from both the Assessment Committee and Ethics Committee, there is no one size fits all approach that can be utilized. Information will continue to be updated, and pushed forward through the professional discourse, and as such, reflections of best practice will continue to be updated and revised to demonstrate updated thinking and understanding of the needs of these communities. As advocates for students in the school setting, it is important to continue to update your knowledge related to best practices when working with specific populations. Respecting and affirming a student’s transgender or nonbinary gender identity is critical to their ability to learn and develop in school (Schools in Transition: A Guide for Supporting Transgender Students in K-12 Schools). Throughout the pre-referral, evaluation planning, assessment and report-writing processes, school psychologists have an obligation to honor each student’s complex identity. 

References

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 

Resources

• Advocating for LGBTQ Students with Disabilities (HRC, NASP, NASSP, NCLR, NEA)
  
  
• Gender-Inclusive Schools (OSPI)
  
  
• Know Your Rights: A Guide for Trans and Gender Nonconforming Students (ACLU)
  
  
• Guidelines for Psychological Practice with Transgender and Gender Nonconforming People (APA)
  
  
• Psychological & Neurological Assessment with Transgender and Gender Nonbinary Adults (APA)
  
  
• A Resource for Incorporating Trans and Gender Diverse Issues into Counseling Psychology Curricula (APA)