Adolescent Gender Diversity Assessment: An In-depth Collaborative Conversation

As more adolescents with differences in gender identity and expressions attend gender clinics worldwide, comprehensive assessment protocols are required to ensure relevant support is provided. For the adolescent and the immediate family the emotional and social processing of gender needs can be a moving target as changing awarenesses promote new priorities. For the practitioner dealing with the unique concerns of adolescents with gender concerns and their families, contrasting perspectives may create dilemmas. This article presents a phenomenological model of assessment for adolescents with differences in gender identity and/or expression using in-depth dialogue exchange. This approach emphasizes the importance of conversational enquiry as a key aspect of assessment and aims to enhance professional awareness of the benefits of engaging adolescents in expansive and open conversation prior to the use of psychological instruments that force direction of thought and may miss the needs of the individual. This article specifically describes the assessment process, providing details and examples. It proposes that a process of in-depth and expanded conversation contributes vital insight for both the adolescent and the practitioner, aiding the understanding necessary for the provision of recommendations, reports and referrals.


Introduction
Over the last ten years clinics have reported a marked increase in the number of adolescents seeking support for concerns regarding gender identity and gender expression [1,2].A New Zealand study by Clark et al. [3] showed that in a study of 8,166 high school students 1.2% identified as transgender while a another 2.5% were questioning their gender.Furthermore there appears to be more adolescents and youth presenting with non-binary, mixed or flexible gender [4,5].The progression towards personal comfort for these adolescents is rarely straight-forward, as complex presentations, teen tendencies and parental attitudes call for focussed and often unique interventions.Furthermore, the contextual presentation of the adolescent is influenced by and embedded in culture, social networks, politics and local communities.Additionally, power dynamics and "transnormativity" 1 may affect the adolescent's freedom of diversity [6].Without comprehensive expanded assessment procedures adolescents presenting with differences in gender identity and/or expression may be deprived of the opportunity to challenge the normative gendered binary expectations [6,7].Professionals therefore need to be cognisant of options outside of the binary and be willing to help adolescents and their parents/family find clarity, identify needs and attain realistic and feasible outcomes.The employment of instruments and scales can be useful for research and diagnostic purposes although they may be misleading if applied on intake, as demands to respond to 'yes' and 'no' or scaled questioning can encourage black and white thinking that may direct attention away from the adolescents real issues and needs.On the contrary allowing the adolescent time to consider their history and circumstances without needing to supply 'fixed' responses to closed and directed questions can allow a recognition of genuine needs to occur and bring any gender confusion to the foreground.
A number of authors have provided important contributions on assessment protocols for adolescents.Those approaches that focus on pre-pubertal children have not been included in this review.The WPATH Standards of Care for the Health of Transsexual, Transgender, and Gender-Nonconforming People [8] outlines the responsibilities of mental health practitioners when working with adolescents with 'gender dysphoria' .They recommend a thorough assessment of gender dysphoria that addresses any mental health concerns and includes examining the "emotional functioning, peer and other social relationships [and] intellectual functioning/school achievement" of the adolescent.They also propose that the practitioner provide education and informed consent regarding the various treatment options and evaluate family functioning while providing or referring the family for education and support.The National LGBT Health Education Centre's documents recommending care for adolescents outlines some general principles for the support of adolescent's physical and mental health [9,10].These principles prioritise the adolescents' health and wellbeing, confidentiality, healthy psychosexual development, screening and treatment of medical and mental illness, management of stigma and psychosocial issues, integrated identity formation and adaptation, and, the provision of specific transgender health needs.They also highlight a practitioner's need for knowledge regarding accurate recognition of gender dysphoria, understanding of psychosexual and gender identity development, family dynamics, employment of tools, questionnaires and resources, use of collaborative teams of professionals, predictors of persistence and clinical issues.Di Ceglie et al. [11] urges practitioners to explore the adolescent's "expectations, gender identity and roles, body image [and] self-perception" as well as seeking the views of family members.Di Ceglie also stipulates "primary therapeutic aims" that include an affirming and nonjudgemental approach, to provide relief for associated difficulties, to curtail secrecy, to encourage curiosity, to explore the adolescent's "mind-body relationship", to promote a team approach with other professionals, to facilitate "symbolic thinking", to assist with maturity development, to allow mourning, to tolerate uncertainty and to inspire hope.De Vries and Cohen-Kettenis [1] pointed out that during the initial phase of assessment, information must be sought from both the adolescent and their parents covering the adolescent's psychosexual development, peer relationships, school application, current "crossgender feelings and behaviour", and family functioning.They also designated that the professional seek information regarding the adolescent's psychological resilience and risk factors, experiences and meaning of sex, sexuality, cross-dressing and body image.Lebowitz et al. [12] adopted a psychosocial approach to determine the adolescent's ability to handle internal and external challenges associated with their gender-nonconforming presentation.In cases where medical intervention was warranted their approach addressed mental health needs and included the assessment of a suitable support system, family needs and informed consent.The assessment proposed by Edwards-Leeper et al. [13] advocated screening for gender dysphoria in association with a "comprehensive psychological evaluation".They included many of the aspects outlined above in order to gauge the adolescents suitability for medical interventions and provide external referrals where adolescents do not meet the criteria for medical interventions.Most of the assessment recommendations above also affirm that an aim of supportive treatment is to alleviate the young person's distress and help the family to tolerate uncertainty.All these recommendations refer to a thorough or comprehensive assessment with little or no information about how to actually conduct such an assessment.This paper presents a detailed description of an intake protocol for adolescents utilizing in-depth conversational enquiry to facilitate such an assessment and enhance adolescents' selfawareness regarding their own unique identity and needs.Instead of focusing on the quantitative aspects of client interviews the in-depth conversational enquiry explores the meaning-making of the issues that arise and encourages the practitioner to become absorbed into the worldview of the adolescent and the family system.Applying an indepth dialogue encourages ongoing reflection allowing for a greater awareness for both the client and the practitioner.Securing an understanding of the adolescent's genuine self-perception in order to provide a sound report with recommendations can take many months or in some cases up to a year or more (depending on how often they attend and on the needs of the adolescent and family).A more lengthy assessment timeframe permits the clinician to establish the ongoing nature of the adolescent's situation, evaluate consistency and allow time for the adolescent to self-reflect in response to probing and challenges that arise in the session.The process may also include providing resources for education, networking for parents and information for families.The word 'adolescent(s)' in this article means adolescent(s) presenting with differences in gender identity and/or expression.The word 'parent(s)' in this article means parent(s) of adolescents presenting with differences in gender identity and/or expression.
The proposed assessment procedure aims to provide the practitioner with an extensive exploration of the presenting issue, the context, dynamics, history and other schemas that may be influencing adolescents and how they see themselves.The approach utilises phenomenology within a collaborative, person-centred framework while acknowledging the vast heterogeneity of gender presentation variations [14,15].The collaborative nature fosters a generative discourse allowing the practitioner to embrace the adolescents meaning and concerns [16].Furthermore the approach arouses empathic recognition of the ways in which adolescents may be denied agency through historical, societal and familial, ignorance and insensitivity [17].
Initial communications with the adolescent and their family often require clarification of the terms used in discourse about gender and related issues.Throughout the media, the internet and various publications is an inconsistency in the use of 'gender' both as a concept and as a word [18].Gender on the one hand is used to describe 'feminine' or 'masculine' behaviour or expression (as it is here) and on the other is used synonymously with 'sex' to refer to one's anatomy.Gender expression is generally 2 the outward manifestation of one's felt gender.However, gender identity is the perception of the self (most often physically) as female, male, neither female nor male, or some combination of both.Whereas, Gender Dysphoria necessarily involves "a marked incongruence between one's experienced/expressed gender and assigned gender" and specifically describes one's discomfort and distress about the primary and secondary physical sexual characteristics of the body not being in alignment with the selfidentified gender identity [19].

The assessment process
The assessment begins with interviewing the adolescent's parents (and sometimes other family members as well) and follows with sessions for the adolescent, alone.It is also beneficial to convene regularly with the parents and the adolescent to encourage ongoing communication between all parties and provide transparency and openness regarding the progression of understanding and the identification of appropriate ways to meet the adolescent's needs.

Parent interview
The interview with parents is structured to gather specifically their view of their child's history including any losses, key events, medical background, strengths and vulnerabilities, interests when young, how puberty affected them, the quality of their friendships and any changes in personality and demeanour.A family tree is taken, noting key relationship dynamics over time, illnesses, mental health concerns and inherited conditions.This will contain information about family members who were lesbian, gay or bisexual, as well as others with gender variances.A family history will include significant events (both positive and negative) and cultural or religious influences that may have a bearing on how the family respond.The parents will be prompted to reflect on their first recognition (if any) of their child being in some way different to other children.The discussion may then include their attitudes and reactions as well as other family members' responses, to specific relevant events and differences in gender identity and expression.Parents can also provide information regarding the adolescent's reliable network of support.Following this it is useful to understand and respond to any concerns and questions they may have regarding the assessment.It is hoped that when parents' feelings and concerns are validated and they are given the time to understand their adolescent's perception of themselves they will be more supportive.

Issues parents may be facing
Parents may not realise that gender variance or dysphoria is a possibility or even exists [13].On the other hand many parents on arrival understand their child's gender differences and are ready to do whatever is necessary to address their child's needs.Historically and in many contemporary societies however, families have not had the exposure or language necessary to understand the experience of gender differences.When a child tries to share their concerns or feelings about their gender with a parent, the parent may become fearful and resort to defences of denial, embarrassment or self-blame, especially as early writings focussed on the mental health particularly of mothers and their role in creating a child's gender dysphoria.Alternatively the parent may become focussed on a 'cause' or turn to religion for answers.This lack of gender literacy can prevent parents from recognising that puberty (which is already a difficult time for any adolescent) is much more difficult for an adolescent with gender dysphoria, and additionally that support for the adolescent's gender reality is essential for overall health [20].Parents may also feel that supporting gender diversity could make their adolescent miserable in the long term or that a punitive approach will move them out of a 'phase' .
Most often parents' feelings of disappointment, betrayal and grief do not get addressed as the focus of professionals is on the child.Parents' expectations of attending a daughter's wedding or hoping for grandchildren may be fading as they gain clarity regarding their child's needs.Parents may also begin to demand answers as the ambiguity of not having a clear sense of their child's future and stability can be overwhelming.This may include feeling a 'loss of control' as they perceive that medical and or psychology professionals provide recommendations they find difficult to implement.They may struggle with using the child's preferred names and pronouns or with allowing the child to express their gender and may want to slow things down to create some space for themselves.This need for space is usually interpreted by the adolescent as a lack of understanding and support.However, maintaining a working relationship between the adolescent and the parents is a crucial factor for their overall health and wellbeing [20].
Parents who have had some exposure to transgender issues may only be aware of stereotypes or misinformation through the media.As a result of these distortions in understanding, parents may make assumptions that gender differences indicate a mental illness, that their adolescent needs reparative therapy or that gender dysphoria will lead to sex work or drug abuse.
Once parents begin to accept the gender differences in their child they may then be faced with many issues of their own.Not only do they have to bear the responsibility of navigating the school, peer, social, psychological and perhaps medical landscapes but they are also left to handle a society that is well behind in the acceptance of gender differences [21].Parents may also have their own grief and concerns not only about their adolescent's future, but about their own relationships and role as advocate.Additionally, they may be concerned about the costs of ongoing support and treatment.Some parents also agonize over separating the normal parenting difficulties from the dilemmas they face in raising an adolescent with gender concerns.One of these issues is how much freedom to allow.Balancing a growing need for independence with concerns about safety may cause conflict [21].
The inclusion of ongoing collaboration with parents while ensuring confidentiality for the adolescent can be a fine line for the practitioner to navigate [22].Ensuring that parents understand the bounds and limits of confidentiality and that the adolescent remains the priority can avoid later difficulties.

Adolescent interview
Given the conversive framework there are three procedures of exploration that the professional can use to address issues with the adolescent.Firstly, by exploring the adolescent's history beginning with first recollections of 'feeling different' (there is no mention of gender) the practitioner is permitting a process of discovery to begin.By then responding with a clarification of the practitioners understanding of what has been said (reflective listening), there is a continual invitation of spontaneous content that guides the session.

Example 1:
Practitioner: What was it that you first noticed about yourself that gave you the idea or had you feel that you were in some way different to others?Marinden: The stuff I do, the way I act… I could just tell it was different… all the girls did other stuff.

Practitioner: So you could tell that what the other girls did was different in some way…
Marinden: Mmm… they used to always be fighting over whose turn it was to use the prams and I didn't care.
Practitioner: So you weren't interested in the prams… what was it that you did care about?Marinden: Well, I was watching the boys and thought I was like them … you know playing with the boys stuff… Practitioner: You saw what the boys were doing and felt that you were like them in some way… Marinden: I used to run around and like… making weird noises.I' d tell everyone I was a unicorn.
Practitioner: What was it that you wanted to do? Marinden: …ar… um… like, I guess… the boys… you know as one of them In this example a developing trust and confidence in the professional relationship emerges as the practitioner invites and allows the adolescent to share their thought processes freely.As the conversation develops the practitioner begins to understand what was and is important to Marinden and how they come to understand and position themselves in their environment.In this exchange the practitioner learns that for Perind expression regarding clothes has meaning and that preferences for dressing had to be hidden.Being asked about the 'secret' , Perind begins to consider, perhaps for the first time how it felt to have such a secret.
In both examples the practitioner's enquiries are open, encouraging and non-directive.There is no reaction to the adolescent's statements as even a positive one could give the impression that the practitioner 'approves' the adolescent's behaviour or thought processes and may unintentionally lead the adolescent to censor or change their response to attract approval.This is not to say that the practitioner ought not to validate the adolescents experience, but rather to provide the validation at summary points during the session.
The second process of exploration occurs after the above 'free exploration' aspect of the assessment is completed.The practitioner can then encourage discussion of specific topics.As the therapeutic relationship is now well established, the adolescent is more likely to engage willingly and openly with subjects that may in some ways feel awkward or uncomfortable.This will also include an appraisal of the adolescent's resilience and ability to tolerate and accommodate change.These topics might include: preferences for pronouns and names (if relevant), the adolescent's general chronological and medical history including any past psychological support, weight concerns, eating and sleeping patterns, gender awareness, family members attitudes, cultural or religious influences, hobbies and interests, knowledge of trans issues and trans people, relevant dreams or fantasies, desires to or not to have children; experiences of depression, anxiety, self-harm or other mental health issues, school, bullying or abuse, puberty, body and sexuality awareness, shame, disclosure and support, substance use, risk, and importantly, awareness and beliefs regarding gender dysphoria, gender identity, gender roles and gender attributions.Some of these factors specifically related to gender identity and expression are discussed below.

Diversity of expression
It appears that more youth are questioning their gender expression and identity and may find congruence outside the expected binary of female or male [3].Although an adolescent may first present with clarity about their gender or gender identity needs, deeper exploration may reveal a more complex picture.Lack of clarity regarding gender identity may be influenced by pressure from family, culture and society to conform to the birth assigned gender.The 'role' expected of the adolescent may be discordant with their preferences for activities and behaviour.It may also appear that the adolescent's gender and physical expression may or may not be aligned with any specific gender identity as they explore various ways to accommodate both their own needs and the expectations of those around them including 'trying out' expected expression and behaviour.
By looking for a way to express their identity adolescents may present or reside within a specific 'scene' or genre, such as goth, emo, anime, punk, grunge, sci-fi, otherkin, freegan or insist on a neutral or androgynous appearance.In this way they may find some acceptance of their difference within the culture while at the same time concealing their gender diversity from their immediate family.While aiming for this validation and some degree of personal comfort, they may also face family or school disapproval of their presentation.
It is therefore useful to explore what gender and gender identity means to the adolescent.Some adolescents may think that not identifying as a typical female or male then means that they are not female or male.Specifically, a female may not want to wear skirts or makeup or to shave their legs, but may not understand that this does not exclude them from identifying as female.Similarly a male might think that if he is not interested in sport or competition and would rather be with girls or wear girls' clothes then he does not qualify as a male.It may help to discuss the multitude of ways people are female or male including examples of people who do not conform to gender stereotypes to help them appreciate that gender identity may appear different to one's gender expression and that gender dysphoria represents one's discomfort with their body.They may choose to maintain the birth sex pronoun until they gain the confidence either in their identity or in being able to speak openly about their gender needs.Some may insist their parents use their preferred pronouns which could be either the pronoun of the opposite sex and gender, or a neutral pronoun such as zhe and zer, the third person neutral terms they, them and their or other preferred pronouns.
Puberty, body awareness and gender dysphoria: Puberty sometimes provides the first signal for parents or the individual themselves that there is a problem that requires attention.The experience of a body becoming masculinised or of menstruation and breast development may be significant factors for an adolescent with differences in gender identity.How the adolescent reacted (is reacting) to these physical changes at puberty, and how they cope with any associated distress furnishes the professional with key data regarding levels of bodily comfort and gender dysphoria.Understanding how the adolescent cares for their body (eg washing or showering), what they feel or think when they look in the mirror and how they choose to wear their clothes that diminish or accentuate certain areas of their body can also provide evidence about their level of congruence with their anatomy.
Sexual orientation identity: With or without the clarity of their gender difference, some adolescents do not know their sexual preferences or attractions.The lack of education or openness available for young people to identify gender concerns may lead to assumptions that confusion about gender identity is explained by a same-sex attraction.An adolescent experiencing gender dysphoria may have come out previously as lesbian or gay and only through exposure to a trans-identifying person, an article, a movie or the internet may the awareness of gender and perhaps body incongruence identification begin.On the other hand pressures to be heterosexual can prevent the adolescent even considering alternative sexual attractions.Also, if an adolescent's body is not congruent with their gender identity, they may not have ever had a sexual attraction.Feeling unable to identify with their sexual characteristics both primary and secondary may leave them feeling that they are non-sexual [23].It may also be helpful to explore (depending on the level of pubertal development) the adolescent's masturbatory patterns, sexual dreams and fantasies, and feelings of sexual satisfaction or frustration as this can also be helpful in diagnosing gender dysphoria.For others a history of sexual abuse may alter their sexual landscape and development of sexual awareness.
The final aspect of the assessment is for the practitioner to understand clearly what it is that the adolescent wants and needs given the information that has been understood.Practitioner: When I bring your parents in I would like to tell them some of the things you mentioned to me that might help them understand how you feel.
[I go through the notes and highlight the points that Dari has expressed I think would help the parents understanding] I would like to tell them how you described puberty -"it feels like an impending doom"… that you worry about your voice, how it frightens you when you hear it go deeper… that you are unable to look at yourself in the mirror… Would this be okay with you?
Dari: [Nods] Are there things that you told me that you would particularly not want me to discuss with them?Dari: I would rather they didn't know about me stealing mum's clothes… Practitioner: Anything else? Dari: Oh yeah… that I skipped school that time last year to hang out Practitioner: Is there anything you would like your parents to do? Dari: Well, to call me 'she' would help, but I don't think they will.It can also be beneficial to ask the adolescent how they imagine themselves, say in five years, as this helps the practitioner to understand the adolescents expected trajectory and timelines (if any).
Working within a team of professionals also contributes to support for the family and provides multiple perspectives while contributing to the overall management of the child's situation.Keeping abreast of the latest research on the administration of hormone blockers as well as cross-sex hormones in adolescents will help to ensure a responsible protocol that is in the child's best interests.

Conclusion
Increasing numbers of transgender youth seeking support indicate a need for greater professional awareness of the assessment process and the variety of issues that may present.A comprehensive assessment process for adolescents not only covers the adolescent's perspective but also acknowledges the systems in which they reside.Therefore a thorough assessment protocol includes an interview with parents and or family as well as the adolescent.
The key components of the assessment procedure described here are: a client-centred, empathic collaborative approach; inclusion of the parents/caregivers perspective on their adolescents history and gender concerns; validation of the parents/caregivers concerns and needs; awareness and acceptance of non-binary gender identities and/or expression; open and expansive dialogue with the adolescent utilising phenomenology and meaning-making; a focus on awareness of gender concerns, gender expression and body image; discussion of past and current mental health concerns, medication and sources of support; identification of issues relevant to the family, culture or religion; investigation of experiences of bullying, abuse and substance use; awareness of familial and external, pressures and influences; notification of eating and sleeping patterns; the adolescents capacity for flexibility and adaptation; and, exploration of interests and visions for the future.
This phenomenological collaborative approach emphasises the establishment of a deep and trusting relationship with the adolescent in order to create the safety necessary for a detailed exploration of their history, thoughts and feelings that later includes a focus on aspects to do with gender identity, expression and dysphoria.This assessment process invites the practitioner to enter into the world of the adolescent, to seek their meaning, to allow the assessment to unfold via an open and engaged conversation initially directed by the adolescent.The scope of the assessment is intended to be far-reaching as well as specific to ensure interventions can not only meet the needs of the adolescent but also to ensure they are also in their best interest.

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say generally as there are many examples where an individual chooses not to outwardly display their felt gender due to past experience, concerns or fear of others reactions Citation: Riley EA (2015) Adolescent Gender Diversity Assessment: An In-depth Collaborative Conversation.J Child Adolesc Behav 3: 241.doi: 10.4172/2375-4494.1000241Child Adolesc Behav, an open access journal ISSN: 2375-4494 Volume 3 • Issue 5 • 1000241

Example 2 :Page 3 of 6 J
Practitioner: What was it that you first noticed about yourself that gave you the idea or had you feel that you were in some way different to others?Perind: I felt odd… like I didn't belong… anywhere really Practitioner: You had this strong sense of not belonging… at all… Perind: I absorbed into myself Citation: Riley EA (2015) Adolescent Gender Diversity Assessment: An In-depth Collaborative Conversation.J Child Adolesc Behav 3: 241.doi: 10.4172/2375-4494.1000241Child Adolesc Behav, an open access journal ISSN: 2375-4494 Volume 3 • Issue 5 • 1000241 Practitioner: What happened when you absorbed into yourself…?Perind: I used my imagination to feel better… I would pretend it was 'dressing opposite day' Practitioner: What did you imagine you would do if there was a 'dressing opposite day'?Perind: I would imagine that there were special days of the week to wear different clothes and pretend I was cross-dressing.I knew I could never wear what I wanted as I' d learnt what was 'wrong' and 'right' and knew it had to be a secret.Practitioner: If you had imagined yourself telling someone this secret, what would you have said at that time?Perind: Mmm… I don't know… I… I don't think I had any words… back then…

Example 3 :
Practitioner: If there was something that you want your parents to know or do what would it be?Dari: That this is who I am… that I'm very serious about this cos I hate my body and everything and it makes me cry sometimes…that I want them to help me through this.Practitioner: When I bring your parents in do you think you could tell them this?Dari:[Nods] Practitioner: Ok, let's see, is there anything else you want your parents to do? Dari: I' d really like some clothes of my own…and to tell my grandparents Practitioner: Do you' d think you be able to ask for these things?Dari: [shakes head] NoPractitioner: Perhaps we could do that together… I could introduce the idea, explaining how it would benefit you and see how they respond… What do you think?