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A mixed-methods examination of transgender and gender nonbinary students’schooling experiences: implications for developing affirmative schools

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A mixed-methods examination of transgender and gender nonbinary students’schooling experiences: implications for developing affirmative schools

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Content A Mixed-Methods Examination of Transgender and Gender Nonbinary
Students’ Schooling Experiences:
Implications for Developing Affirmative Schools
By
Cary Leonard Klemmer
A Dissertation Presented to the
FACULTY OF THE USC GRADUATE SCHOOL
UNIVERSITY OF SOUTHERN CALIFORNIA
In Partial Fulfillment of the
Requirements for the Degree
MASTER OF SOCIAL WORK / DOCTOR OF PHILOSOPHY
SOCIAL WORK
August 2020
Copyright 2020 Cary Leonard Klemmer

ii
Dedication
This work is dedicated to my many supportive friends, my parents counted among them,
who constantly ground and center me toward the joy of life, and to LGBTQ people who fill our
world with love. Further, this work has been done in loving memory of my ancestors who
nourished themselves and their families, and who have brought me forth to this day.

iii
Acknowledgements
The task of acknowledging all those who have imparted on my life the means for critical
reflection and growth is impossible. Nonetheless, I will attempt to name all those for whom
without this dissertation would not be as challenging and rewarding of a process.
To my dissertation committee. To Dr. Jeremy Goldbach for demanding space for LGBTQ
research and people and sharing of your time and resources without question. To Dr. John
Blosnich, your arrival at USC was basheret, I wish I had had more time to learn from you. To
Dr. Laura Ferguson, your support has kept me moving through the challenges of doctoral
training and you continue to inspire through your dedication to others. To Dr. Ron Avi Astor,
your embrace of science and kindness hand-in-hand to improve the lives of children across the
world is outstanding, you define what it is to be a mensch.
To the USC Suzanne Dworak-Peck School of Social Work PhD Program, staff and
faculty. To Dr. Michael Hurlburt, you demonstrate a deep commitment to student wellbeing and
set an example of integrity that I will carry with me. To Malinda Sampson for your presence and
caring. To Dr. Concepción Barrio, for your compassion towards me and all. To Dr. Kristen
Zaleski for validating my truths. To Dr. Larry Palinkas for your mentorship and kindness. To Dr.
Sheree Schrager and Dr. Mary Rose Mamey, for teaching and sharing on the joy of statistics.
To my student colleagues and friends. To Joshua Rusow, your friendship and caring for
others has been a great lesson for me, thank you. To Dr. Hadass Moore, for challenging me to
think wider and deeper about myself. To Dr. Melissa Bird, for bringing me to the Channel
Islands. To Shannon Dunlap for your generosity. To Daniel Green, for being a confidant. To
many others who have shared their wisdom, warmth and time with me: Sapna Mendon, Taylor

iv
Harris, Judith Perrigo, Robin Petering, Rory O’Brien, Katie McNamara, Jessica Rampton and
Jaih Craddock.
To Dr. Shanna Katz-Kattari, your energy and commitment to shine light and create
critical and feminist dialogue in social work has nurtured me. To Dr. Steve Sussman, for your
friendship. To Siouxsie Calderon, for your work in the spirit of social work rising. To Julie
Torrence for helping me open to more.
To my friends and family. You have nurtured and held me through this process, and it
would not have been possible without your love and community. Thank you Machiko Yasuda,
LiAnn Ishizuka, Gi Yun, Winny Wen, Sophie Reiff, Ian Giang Pham, Inna Zilber, Daniel
Engelskirger, Isadora Rivers, Evelyn Larios, Aron Seegers, Amy Farrow, Zoe Nicholson, Marvin
Brown, Shawn Lee, Kylie Justa Chance, Adana Martinez, Shaina Silver, Kiran Bal, Adam
Brooks, Jenny Sonenberg. To Andrew and Trinity, your love has sustained me, redirected me,
and kept me going. Thank you. To my parents for safety, shelter and many lessons. To my
cousins Freya Kay and Mike and Val Katz for your love that is very much felt. To the Emard
family for embracing me.
In acknowledgment of the grace and wisdom that so many have imparted upon me, I
dedicate my efforts henceforth to developing a society where all beings may work toward their
own and others highest good.

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Table of Contents

Dedication ....................................................................................................................................... ii

Acknowledgements ........................................................................................................................ iii

List of Figures and Tables............................................................................................................. vii

Abstract ....................................................................................................................................... viii

Chapter 1. Project Specific Aims .................................................................................................... 1
Aims & Research Questions ................................................................................... 5

Chapter 2. Dissertation Introduction ............................................................................................... 7
Background: Existing Knowledge on Transgender and Gender Nonbinary
Youth and Adolescents ........................................................................................... 7
Health Significance: A Review of the Health of Transgender and Gender
Nonbinary Populations.......................................................................................... 10
Theoretical Framework ......................................................................................... 12
Violence & Gender Minority Stress ..................................................................... 15
Ecological Systems Theory and School Violence Prevention .............................. 18

Chapter 3. (Study 1): School Violence, and School Climate: The Experience of Transgender
and Gender nonbinary Students .................................................................................. 28
Abstract ................................................................................................................. 28
School Violence, and School Climate: The Experience of Transgender and
Gender Nonbinary Students .................................................................................. 30
Methods................................................................................................................. 34
Results ................................................................................................................... 37
Discussion ............................................................................................................. 40
Conclusion ............................................................................................................ 47

Chapter 4. (Study 2): The Mediating Effect of School Stress and Violence on Suicide
Ideation and Attempt Among Transgender and Gender Nonbinary Young People ... 55
Abstract ................................................................................................................. 55
The Mediating Effect of School Stress and Violence on Suicide Ideation and
Attempt among Transgender and Gender Nonbinary Young People ................... 57
Methods................................................................................................................. 63
Results ................................................................................................................... 66
Discussion ............................................................................................................. 69
Conclusion ............................................................................................................ 74

Chapter 5. (Study 3): A Qualitative Exploration of the Experiences of Transgender and
Gender Nonbinary Adolescents with Support and Stress in School ........................... 80
Study 3 Abstract .................................................................................................... 80

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A Qualitative Exploration of the Experiences of Transgender and Gender
Nonbinary Adolescents with Support and Stress in School.................................. 82
Methods................................................................................................................. 87
Results ................................................................................................................... 91
Discussion ........................................................................................................... 104
Conclusion .......................................................................................................... 112

Chapter 6. Conclusion ................................................................................................................. 115
Review of Major Findings and Integration with Existing Research ................... 117
Implications for Future Research, Policy and Practice ....................................... 126
Conclusion .......................................................................................................... 136

References ................................................................................................................................... 137

vii
List of Figures and Tables
Figure 2.1. The Gender Minority Stress Model Adapted from Meyer (2003) and Testa
et al. (2015). ................................................................................................................ 27

Table 3.1. Weighted Sample Characteristics by Gender Identity, 2015 and 2017. ...................... 49

Table 3.2. Adjusted Logistic Regression Results, Gender Identity and School Violence,
2015 and 2017. ........................................................................................................... 51

Table 3.3. Adjusted Logistic Regression Results, Gender Identity and School Climate
2015 & 2017, HKCS. .................................................................................................. 52

Table 3.4. Logistic Regression Results Adjusted for Urbanicity, 2015 & 2017, HKCS. ............. 53

Table 4.1. Sample Characteristics (N = 589). ............................................................................... 75

Table 4.2. LGBTQ-based School Stress and Violence, Suicidal Ideation, and Suicide
Attempt Among Sample (N = 589). ............................................................................ 76

Table 4.3. Mediation Analysis Results (N = 589). ....................................................................... 77

Figure 4.1. The Role of LGBTQ-based School Stress and Violence in Mediating the
Association between Minority Gender Identity and Suicidality. ................................ 79

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Abstract
Transgender and gender nonbinary (TGNB) young people’s experiences are emerging in
scientific literature. Existing indications suggest that these young people face challenges to their
mental health including anxiety, depression and high levels of suicide ideation and attempt
relative to their cisgender (i.e., not transgender) peers. More thorough and rigorous examinations
of TGNB young people’s lived realities are necessary in order for behavioral health
professionals, such as school social workers, to address their needs in the school place. The
present dissertation used quantitative and qualitative methods to explore data from three distinct
studies that engaged TGNB young people and queried their experiences. The first study was
epidemiological in nature and used the Healthy Kids Colorado Survey to compare the reports of
school violence and school climate perceptions of TGNB students with cisgender peers. The
second study used data from sexual and gender minority young people accessing services at a
suicide crisis hotline and explored the mediating role of LGBTQ-targeted school stress and
violence and its role in mediating the relationship between gender identity and outcomes of
suicide ideation and attempt. The final study explored the lived realities of TGNB students and
their parents in relation to schooling using in depth life history calendar interviews. Across the
three studies, it was found that TGNB students reported greater school violence and felt less
connected to their school places than did their cisgender peers. Qualitative interviews, and data
across the three studies as a whole, show that there are great opportunities and great need for
reform of school sites toward the affirmation and support of TGNB students. Promising
affirmative practices and policies for schools and school districts are discussed throughout and
would likely lead to gains in the mental health and wellbeing of TGNB and all young people.

1
Chapter 1. Project Specific Aims
Transgender and gender nonbinary (hereafter TGNB) adolescents are those whose gender
identity (i.e., their internalized sense of gendered self as either a boy/man, girl/woman or other
gender) differs from that expected of them given their sex assigned at birth (The GenIUSS
Group, 2014). Rigorous research is still needed to establish accurate estimates of prevalence of
TGNB gender identity among young people (the present dissertation uses samples of varying
ages ranging between ages 12-24, throughout samples are described as youth and/or adolescents
when ages 18 and younger, and as young people when ages 24 and younger). Many estimates
exist that range from between less than one percent to over 12% of all adolescents with an
overall ratio of 1:1 between natal females and males (Olson-Kennedy et al., 2016).
Existing indications suggest that TGNB adolescents experience heightened rates of
violence that begin early in their lives and last into adulthood (Klemmer et al., 2018; Stotzer,
2009, 2017). For example, a recent review of gender-based violence literature among TGNB
populations reported that nearly 90% of TGNB people report experiences of gender-based
violence (Wirtz et al., 2018). Violence experienced by TGNB people ranges from invalidation of
an individual’s gender identity through gender-based microaggresions (e.g., inaccurate use of
gender pronouns; Chang & Chung, 2015), as well as verbal and physical assault. Further, over
the last decade, over 165 murders of TGNB individuals were recorded in the U.S., however, no
national surveillance system exists and the true estimate of TGNB homicide is likely much
higher (Dinno, 2017; Wirtz et al., 2018).
TGNB adults and adolescents have also been shown to experience very high rates of
suicidality (i.e., suicide attempt and suicide ideation) relative to their cisgender peers. For
example, one recent study of a New York-based community sample of adult transgender women

2
found that 53.5% experienced lifetime suicidal ideation, 35% reported lifetime experience of
having a plan for suicide, and 29.7% reported at least one attempt of suicide (Reisner et al.,
2016). High rates of suicidality have been observed among TGNB adolescents as well. One
online Canadian study found that 65 % of TGNB 14-18 year olds reported having a plan for
suicide over the last year (Veale et al., 2017). Gender identity-based violence is thought to be a
main contributor to the observed elevated suicidality among TGNB people compared with
cisgender general populations (Griner et al., 2017; Testa et al., 2012; Xavier et al., 2005).
Schools are one context where TGNB adolescents encounter violence in the form of
bullying and harassment, as well as through school structures that ignore and invalidate TGNB
students’ needs (Gordon et al., 2016; De Pedro & Esqueda, 2017; Reisner, Greytak, et al., 2015;
Toomey et al., 2012). A 2015 national survey on the school experiences of lesbian, gay, bisexual,
and TGNB adolescents found that TGNB youth felt the most unsafe and reported the greatest
amount of violence compared to their cisgender sexual minority (i.e., lesbian, gay and bisexual)
peers (Kosciw et al., 2016). In this national school climate survey nearly 60% of TGNB
adolescents were verbally harassed compared to only 6% of their cisgender male peers (Kosciw
et al., 2016).
School violence has been found to consistently correlate with many negative outcomes
for all youth including depression, anxiety and suicidality (Benbenishty & Astor, 2005; Burton et
al., 2013; Connolly et al., 2016), as well as low academic performance (Thapa et al., 2013).
Emerging literature shows a similarly negative relationship of school victimization on TGNB
adolescents’ behavioral health including suicidality and academic performance (Russell et al.,
2011). More research is needed however to understand and prevent school violence that targets
TGNB students and the associated negative mental health outcomes. Prevention of school

3
violence toward TGNB students may result in significant long-term health gains for TGNB
people across their lifespan (Reisner et al., 2016; Russell et al., 2011; Toomey et al., 2018).
A primary contributor to the prevalence of violence in schools overall is a school’s
climate (Kosciw et al., 2016; McGuire et al., 2010; Toomey et al., 2012). Systematic review has
shown that positive school climate is a consistent and strong predictor of a spectrum of
outcomes, including safety, for general populations of students (Thapa et al., 2013). School
climates arise from individuals and groups experiences with schooling that reflect the values,
norms, goals, interpersonal relationship qualities, teaching and learning practices, and
institutional organization of the school environment (Cohen et al., 2009). Essential factors
indicative of a positive school climate are those practices that promote individuals feeling
socially, emotionally and physically safe (Cohen et al., 2009; Thapa et al., 2013).
Factors that may contribute to a positive school climate for youth generally may also
improve the perceptions of school climate for TGNB adolescents, though research in this area is
lacking and TGNB students school climate perceptions are not well understood (Day et al.,
2018). Nearly two decades of research on sexual minority students as a whole has suggested that
the presence of supportive student organizations (e.g., Gay-Straight Alliances or GSAs), teacher,
staff and peer social support (e.g., through bullying intervention and TGNB student affirmation),
specifically enumerated anti-bullying policies for LGBTQ students, access to resources such as
comprehensive sexual health education, and representation of LGBTQ individuals in curriculum
are the most salient currently identified factors relevant for LGBTQ student safety and postive
school climate (De Pedro et al., 2018; Kosciw et al., 2016; Yeung & Leadbeater, 2010).
There is a lack of literature providing evidence-based guidance for school personnel (e.g.,
school social workers) on how to affirm and support TGNB students (Graybill & Proctor, 2016).

4
Examination of TGNB students using robust representative samples, as well as assessing the role
of individuals involved in their schooling (e.g., parents and teachers) is indicated (Goldblum et
al., 2012; Olson-Kennedy et al., 2016; Toomey et al., 2018). Currently, studies show that TGNB
students report limited support in school and from adults at school (Clark et al., 2014; De Pedro
et al., 2017; Kosciw et al., 2016). Emerging evidence has also demonstrated poor outcomes and
perceptions of school climate in rural areas, though more research is needed to understand the
role of rurality on the school-based outcomes of TGNB students (De Pedro et al., 2018; Fisher et
al., 2014). As a step towards addressing the current limited literature on TGNB students’
experiences and needs, this dissertation examines TGNB students’ experiences of violence, the
relationship of school violence and mental health (i.e., suicidality), and TGNB students’
perceptions of school climate. This dissertation uses 1) state-wide data from the Youth Risk
Behavior Surveillance System from Colorado at two time points (i.e., 2015 and 2017), 2) data
from a national study of the experiences of LGBTQ adolescents accessing a suicide prevention
crisis service provider, and 3) life-history interviews with TGNB students and their parent care-
givers on their experiences navigating stress and support in school. These three studies fit
together through a mixed-methods examination of the experiences of TGNB young people
beginning with a statewide epidemiological view of school violence and school climate
experiences, moving then to understand the role of school climate (measured through LGBTQ-
focused school stress and violence experiences) amongst a smaller national sample accrued at a
suicide crisis-hotline, and ends with a qualitative inquiry into these experiences among a sample
of TGNB students in Southern California. These analyses will address and are organized under
the following aims and research questions:

5
Aims & Research Questions
Study 1
Aims
1. To estimate prevalence of school-based violence (i.e., school and bullying violence)
among in-school TGNB adolescents.
2. To document perceptions of school climate among in-school TGNB adolescents.
3. To examine if TGNB students are more likely to report violence (i.e., school and bullying
violence) compared to cisgender adolescents controlling for demographic characteristics
(i.e., age, reported sex, racial and ethnic identity, and sexual orientation).
4. To examine if TGNB students are less likely to report positive school climate compared
to cisgender adolescents controlling for demographic characteristics (i.e., age, reported
sex, racial and ethnic identity, and sexual orientation).
5. To examine if adolescents’ school urbanicity (i.e., rural or urban regional location) is
related to TGNB adolescents’ reports of violence (i.e., school and bullying violence) and
perceptions of school climate.
Study 2
Aim
1. To document the prevalence and relationships between LGBTQ-based school stress and
violence experiences, suicide ideation severity and suicide attempt among a sample of
young people seeking help at a suicide-crisis hotline.

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Research Questions
1. Do LGBTQ-based school stress and violence experiences mediate the association
between TGNB gender identity and suicide ideation severity in a sample of sexual and
gender minorities accessing a suicide-crisis hotline?
2. Do LGBTQ-based school stress and violence experiences mediate the association
between TGNB gender identity and reports of suicide attempt in a sample of sexual and
gender minorities accessing a suicide-crisis hotline?
Study 3
Research Questions
1. How do TGNB students and their parent caregivers describe support in their schooling
experiences?
2. How do TGNB students and their parent caregivers describe stress in their schooling
experiences?
Given a lack of empirical literature that comprehensively documents the school-based
experiences of transgender adolescents using robust data (Day et al., 2018; McGuire et al.,
2010), the proposed project will provide social work, public health and allied practitioners
important prevalence estimates of school and bullying violence, suicidality, and will record
TGNB students perceptions of school climate from robust data at the regional, state and national
levels. This dissertation aims to provide school social workers and their allies a slightly more
focused understanding of factors in schools that establish risk and create resilience among TGNB
students.

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Chapter 2. Dissertation Introduction
Background: Existing Knowledge on Transgender and Gender Nonbinary Youth and
Adolescents
In recent years, there has been increased social recognition of transgender and gender
nonbinary (hereafter TGNB) individuals. Increased social recognition has been made possible in
part due to critiques of the gender binary (i.e., the widely accepted social structure that divides
sex and gender into two non-intersecting poles) and expanded social awareness and acceptance
of sexual and gender minorities (Burdge, 2007; Butler, 1990; The GenIUSS Group, 2014;
Mehrotra, 2010). TGNB individuals comprise a large group of people across the globe whose
gender expressions and identities are different from that expected of them given the sex
categories (i.e., male or female) assigned to them at birth (Hendricks & Testa, 2012; The
GenIUSS Group, 2014). The 2015 United States Transgender Survey (USTS), one of largest
convenience samples of TGNB adults ever collected found that that while 62% of the sample
identified as either a transgender man or transgender women, over one third (35%) had a gender
nonbinary identity such as gender queer, or gender fluid (James et al., 2016). Research for the
last half-century has almost exclusively focused on the experiences of transgender men and
transgender woman and the needs and experiences of TGNB as a whole are in need of continued
social scientific exploration (James et al., 2016). The needs and experiences of gender nonbinary
individuals may differ from those of transgender men and transgender women, and without a
fuller understanding of these experiences, service providers cannot address their needs.
Recent estimates show that TGNB individuals comprise a notable and unignorably large
portion of society whose needs must be addressed by the social institutions with which they
engage. For example, a 2016 report of the Williams Institute at the University of California Los

8
Angeles, a legal research organization devoted to advocacy for LGBTQ populations, found that
the national estimate of TGNB individuals living in the U.S. was 1.39 million individuals, with
the upper bound of study confidence intervals showing that the adult population may be up to
2.29 million individuals, or nearly 1% of the U.S. population as a whole (Flores et al., 2016).
This finding suggests TGNB individuals comprise a group larger than the population of many
major U.S. cities (e.g., Portland, Oregon, or Seattle, Washington) (U.S. Census Bureau, 2016).
Both the preceding study, and meta-analysis of population prevalence estimates have found that
young TGNB individuals comprise greater than 50% of the identified population (Flores et al.,
2016; Meerwijk & Sevelius, 2017).
Rigorous research is still needed to establish accurate estimates of prevalence of TGNB
gender identity among youth and adolescents. Many estimates exist ranging from between less
than one percent, to over 12% of all adolescents, with a ratio of 1:1 between natal females and
males who are transgender (Olson-Kennedy et al., 2016). Further, estimates from the California
Health Interview Survey (CHIS) 2015-2016 administration cycle found that 27% of all
adolescents in the state reported nonconformity to socially held expectations of gender
expression (Wilson et al., 2017). The prevalence of expressed TGNB identities may be on the
rise given changes in society toward increased visibility, understanding and acceptance of gender
diversity. Overall, research on the prevalence and experiences of TGNB adolescents is relatively
small and more work is needed.
An important life event that is indicative of TGNB individuals’ experience is a period of
coming to a realization that one is TGNB and making decisions to engage in a process of gender
identity and expression affirmation (Budge et al., 2013; Burnes et al., 2016). This transition is a
multi-faceted process that can involve social, medical, and legal dimensions, and arguably lasts

9
throughout an individual’s lifetime as they continually navigate their presence as TGNB people
in society (Levitt & Ippolito, 2013). Social dimensions of transition include an TGNB
individual’s “stepping out,” a period when they begin to dress and express their desired gender
identity through clothes, speech and other mannerisms at home or in public settings. Medical
transition can entail feminizing and/or masculinizing procedures and/or cross-sex hormone
therapy/pubertal suppressants to alter the physical presentation of the body so as to be more in-
line with individual’s desired gender expression (Olson-Kennedy et al., 2017). Legally, transition
includes but is not limited to changing legal gender markers on government issued identification.
Overall, gender identity and expression transition provide social and psychological affirmation to
TGNB people (Sevelius, 2013). For example, access to social and medical transition is
associated with improved psychological wellbeing (Glynn et al., 2016), and has been shown to
mitigate the negative relationship of violence with mental health among adult transgender
women (Klemmer et al., 2018).
Transition can begin very early in the lives of TGNB youth and adolescents (Ehrensaft,
2016), and the social institutions that these young people interface with are important areas that
likely contribute to their overall health (Durwood et al., 2017). One particularly relevant social
institution that many TGNB young people interact with from young ages are schools (Orr &
Baum, 2015). Retrospective study of TGNB adults’ childhood school experiences in the USTS
demonstrated that 77% of the sample who were out or perceived as TGNB by others during their
school years experienced some form of mistreatment in schools including verbal harassment, not
being allowed to wear clothing in alignment with their gender identity, harsher discipline than
peers, and physical and sexual assault because others thought they were TGNB (James et al.,
2016). School-based professionals and advocates of youth (e.g., school social workers, school

10
psychologists, educators, administrators and school policy makers) have made calls to address
the etiology of negative school-based experiences that can have a profound negative impact on
the health and mental health of TGNB young people (American Psychological Association &
National Association of School Pyschologists, 2015; Bonell et al., 2013; McGuire et al., 2010;
Testa et al., 2012).
Health Significance: A Review of the Health of Transgender and Gender Nonbinary
Populations
Transgender and Gender Nonbinary Adult Health
The preponderance of existing literature over the last two decades has focused on TGNB
adults and has found high prevalence of negative mental health experiences including
psychological distress, suicidal ideation and attempt, substance use and elevated HIV prevalence
relative to the general population (Clements-nolle et al., 2001; Clements-Nolle et al., 2006; Haas
et al., 2011; Kellogg et al., 2001; Nuttbrock et al., 2014; Xavier et al., 2005). For example,
research with adults in different metropolitan areas has shown an HIV prevalence of 32% in one
sample (Xavier et al., 2005) and nearly 40% in another (Rapues et al., 2013). Further, estimates
of anxiety and depression are high (Bouman et al., 2017; Klemmer et al., 2018), with one study
showing 35% of adult transgender women with current clinical depression, and a significant
relationship between experiences of gender identity-based discrimination and the sample’s
severity of depression (Bazargan & Galvan, 2012). As for suicide, studies have demonstrated a
range of suicide attempt prevalence between 26% and 45% (Clements-Nolle et al., 2006; Grant
et al., 2011), with the USTS showing an attempt rate of 40%, nine times higher than that of the
general U.S. population (James et al., 2016). Finally, as for substance use among this group of
adults, one study has shown that nearly 50% report last three-month binge drinking, with 19%

11
reporting last year illicit substance use (Keuroghlian et al., 2015). These studies demonstrate a
burden of negative behavioral health among TGNB adults relative to their cisgender adult peers
in the U.S. general population.
Transgender and Gender Nonbinary Adolescent Health
The negative behavioral health documented among TGNB adults has been shown to
begin early in these individuals lives. Literature on the health and mental health experiences of
TGNB adolescents are relatively limited in comparison to that of TGNB adults, though existing
studies document similarly heightened prevalence of negative health outcomes among this group
of youth (Connolly et al., 2016). For example, recent review of the mental health experiences of
TGNB adolescents revealed existing estimates of depression, dysthymia, and depressive
symptomatology to range from as low as 12.4% in one sample, to as high as 64% in another,
with many estimates between 30% and 60% (Connolly et al., 2016). Additionally, a study using
a diverse, multi-city sample of young transgender women found that 35.4% of the sample had at
least one major depressive episode, with nearly 15% of the sample presenting with that diagnosis
at the time of study (Reisner et al., 2016). PTSD has also been found at high rates among TGNB
youth. One multi-year study of 16-24 year old transgender girls living in the San Francisco bay
area using peer networks and respondent driven sampling found a prevalence of PTSD that
exceeded 60% (Rowe et al., 2015; Wilson et al., 2016). Elevated rates of substance use have also
been observed, in one study (N = 292) 69% reported any illicit drug use in the last 6 months, and
82% and 51% reported any alcohol use and binge drinking in the last 6 months respectively
(Rowe et al., 2015). Separately, a California statewide survey of adolescents found that TGNB
youth exhibit a rate of substance use ranging from 2.4 to 4 times that of their cisgender peers
across substances (Day et al., 2017), with other estimates reflective of these findings (De Pedro

12
et al., 2017). Wide ranging estimates of TGNB young people’s mental health experiences are in
part a result of the reliance of many studies on small sample sizes, convenience sampling
procedures, and enrollment through clinics and service settings (Connolly et al., 2016).
Suicide Ideation and Suicide Attempt Among Transgender and Gender Nonbinary
Adolescents
Additionally, like TGNB adults, TGNB adolescents have rates of suicidal ideation and
attempt that are far greater than their cisgender adolescent peers (Perez-Brumer et al., 2017).
Results from the national Canadian Community Health Survey and the Canadian Trans Youth
Health Survey demonstrate these differences. While only 15.4% of the Canadian general
population had considered suicide in their lifetime, almost 75% of Canadian transgender
adolescents had done the same, a prevalence difference of almost 60% (Veale et al., 2017). As
for last year attempted suicide, TGNB youth reported a rate of attempt of 11.3% compared to
cisgender youth’s prevalence of 0.7%, suggesting a relative risk of suicide attempt for TGNB
adolescents of 16.14 compared to their cisgender peers. The rates of TGNB suicide ideation and
attempt reviewed here and documented elsewhere may be indicative of a public health crisis
(Clark et al., 2014; Goldblum et al., 2012; Reisner, Vetters, et al., 2015; B. D. M. Wilson et al.,
2017). Research to understand the risk and supportive factors for TGNB adolescents suicide
ideation and attempt are necessary.
Theoretical Framework
Minority Stress Theory Origins and Sexual Minority Stress Theory
The numerous negative health experiences documented among lesbian, gay, bisexual,
transgender and queer (LGBTQ) populations have largely been attributed to the negative
consequences of minority-specific stigma and stress encountered by these groups in the social

13
environment (Goldbach & Gibbs, 2017; Institute of Medicine, 2011; Klemmer et al., 2018;
Meyer, 2003; Testa et al., 2015). The sexual minority stress model was first introduced by Meyer
(2003) in a foundational piece that hypothesized on the stress processes of sexual minority (i.e.,
LGB) individuals. Meyer used the earlier conceptual work of Lazarus and Folkman (1984) to
organize the sexual minority stress model on a continuum leading from distal stress (also called
environmental stress; Lazarus & Cohen, 1977) to proximal stress, culminating in ultimate mental
health outcomes. Distal stressors are those sources of stress, stigma and discrimination that are
external to individuals, they are the structures of society that are interpreted by individuals
through various cognitive and emotional forms of appraisal (Folkman et al., 1986; Meyer, 2003).
These internalized forms of appraisal are the proximal sources of stress. Meyer’s sexual minority
stress model posited that, for LGB individuals distal sources of stress are primarily external
objectively stressful events, either acute or chronic, such as physical violence and victimization,
or targeted discriminatory policies. Meyer further hypothesized that proximal stressors for sexual
minority individuals are the expectations of such acute or chronic events, the internalization of
negative social attitudes, and concealment of one’s sexual minority status due to fear of
repercussions (Meyer, 2003). Meyer (2003) also proposed the importance of coping and social
support in the continuum between social stress and negative mental health outcomes. Supportive
factors are posited to have a buffering role on the negative impact of social and distal stress on
behavioral health outcomes. Much research has been conducted using the minority stress
framework, which has illustrated the minority stress processes of LGB adults and adolescents
from distal stressors to negative behavioral health outcomes (Goldbach & Gibbs, 2015, 2017;
Hatzenbuehler, 2009, 2014). Recent notable contributions to this body of literature include the

14
development of psychometrically rigorous tools for the assessment of sexual minority stress
(Schrager et al., 2018).
Gender Minority Stress Theory
Over the past decade, a model of gender minority (i.e., TGNB) stress has been adapted
using Meyer’s (2003) model of sexual minority stress (Hendricks & Testa, 2012; Reisner,
Greytak, et al., 2015; Testa et al., 2015). This model (see Figure 1) is the central conceptualizing
framework of the current dissertation. Gender minority stress theory posits that subjection to
chronic sustained stress in the form of environmental stigma and discrimination (i.e., distal
stress) impact individuals’ internalized expectations of rejection, levels of internalized
transphobia (i.e., self-hatred due to one’s TGNB gender identity) and the concealment of their
minority gender identity (Testa et al., 2015, 2014). As in the sexual minority stress framework,
here as well the distal to proximal continuum of stress is thought to limit TGNB individuals’
coping resources, and with limited social support, to be an important explanatory factor for
documented negative behavioral health experiences (e.g., suicidality) of TGNB populations
(Goldblum et al., 2012; Testa et al., 2017).
Social Support in the Gender Minority Stress Model.
The gender minority stress framework suggests that supportive others moderate
discriminatory and victimizing experiences so that even in the presence of chronic and/or acute
distal stress, TGNB individuals’ negative health outcomes can be protected against by support
from others. Emerging research has begun to demonstrate the positive impact that social support,
especially supportive adults, parents and peers has on bolstering these youths’ coping skills and
resiliency. For example, research with a group of TGNB adolescents presenting for care at a
children’s hospital in the western U.S. was the very first to demonstrate that support from parents

15
was associated with greater quality of life (β = 0.324, p = .02), decreased perceived burden of
being TGNB (β = -0.441, p ≤ .001) and decreased depressive symptomatology (β = -0.263, p
= .05) (Simons et al., 2013). More recent and methodologically rigorous research on the
violence, mental health and social support experiences of TGNB adolescents demonstrated that
TGNB adolescents reports of parental closeness protected against negative mental health
outcomes (Wilson et al., 2016). Youth that were close with their parents had reduced odds of
psychological distress (OR = 0.3, 95 % CI = 0.1–0.9), PTSD symptomatology (OR = 0.4, 95 %
CI = 0.2–0.7), depression (OR 0.4, 95 % CI = 0.2–0.9), and stress related to thoughts of suicide
(OR = 0.2, 95 % CI = 0.0–0.9) relative to those adolescents who were not close to parents. Also,
qualitative research with clinically traumatized TGNB adolescents of color has shown that
connection to adults is described as related to resilience. For example, one respondent in a
qualitative study shared that the support they received from their mother was a buffer against the
negative impact of rejection elsewhere in their lives, stating, “I could walk with my head up with
her approval” (Singh & McKleroy, 2011, p. 38).
Violence & Gender Minority Stress
Violence and Victimization in the Lives of Transgender and Gender Nonbinary People
Gender-identity based violence and victimization of TGNB people has been observed at
high rates worldwide and in the U.S. (Blondeel et al., 2018; Fernández-Rouco et al., 2017; Wirtz
et al., 2018). Systematic review of municipal, county, state and federal crime statistics show
elevated rates of documented violence among TGNB people compared with cisgender
populations that range from verbal and physical harassment to homicide (Dinno, 2017; Stotzer,
2008, 2009). Particularly vulnerable to this violence are TGNB individuals of color, especially
those of Latinx and African American racial and/or ethnic identity (Dinno, 2017; Garofalo et al.,

16
2006; Xavier et al., 2005). For example, Dinno (2017) reported that TGNB people of colors’
relative risk for homicide is well over that of cisgender women in the general U.S. population.
The violence experienced by TGNB individuals is not confined to acute verbal and
physical attack but also includes other forms of gender-identity based violence in the form of
stigma and gender identity-based microaggressions (Chang & Chung, 2015; White Hughto et al.,
2015). TGNB populations encounter stigma at the structural level which include for example
living under cisgender norm enforcing policies and social expectations, and a lack of access to
institutions with staff and providers that understand and affirm TGNB people. At the
interpersonal level TGNB people experience stigma in the form of direct experience of
discrimination or rejection by health care providers, employers, and/or by family members
(White Hughto et al., 2015). Chronic forms of discrimination perpetrated against TGNB
individuals have been classified as gender-based microaggresions and are categorized by either
subtle antagonistic insults that are intentional or unintentional (Chang & Chung, 2015). These
microaggresions can be brief, daily, behavioral, verbal, and/or environmental insults that include
explicit derogation through verbal or nonverbal attacks, communications that degrade a person’s
identity, and communications that deny the psychological thoughts, feelings, and reality of a
person (Wing Sue et al., 2007). These experiences are related to intrapersonal proximal forms of
gender minority stress such as internalized transphobia (White Hughto et al., 2015). Acute verbal
and physical violence as well as chronic stress due to sustained encounters with gender-based
microaggresions are not confined to adult TGNB individuals. All indications suggest that
violence and discrimination begin early in the lives of TGNB people (Stotzer, 2009).

17
School Violence and Schools as Sites of Gender Minority Stress
Schools are one context relevant to most every adolescent because of the significant
amount of time spent at school and the potential subjection of youth to potentially negative
health altering experiences while at school (Lester et al., 2017). Decades of research have
demonstrated that school violence is one particularly important school-based experience that can
have a lasting negative impact on the positive healthy development of youth and adolescents
(Thapa et al., 2013; UNESCO, 2017). School violence is physical, sexual, and/or psychological
violence (e.g., having been in a fight, having missed school due to fear for one’s safety, or
having been sexually harassed or assaulted) perpetrated by teachers, students and/or other school
staff intended to harm, physically or emotionally, persons in schools (Benbenishty & Astor,
2005; Rice et al., 2015; UNESCO, 2017). Bullying, which can occur in person or online (cyber
bullying), is an impactful type of school violence embodied by repeated exposure to negative
actions that inflict harm or discomfort, and a real or perceived power imbalance between
perpetrator/s and victim/s (Benbenishty & Astor, 2005; Cardoso et al., 2017; Rice et al., 2015;
Sterzing et al., 2014; UNESCO, 2017).
School violence affects one’s behavioral, social, cognitive and emotional wellbeing and
is associated with absenteeism and academic failure as well as negative mental health outcomes
that include depression, suicidal ideation, and substance use (Benbenishty et al., 2018; Lester et
al., 2017; Russell et al., 2016; UNESCO, 2017). Findings on the negative impact of school
violence have also been found among TGNB adolescents, especially when experienced violence
was perceived to have been due to an individual’s status as TGNB. One study found that TGNB
adult respondents who reported experience of school violence as adolescents had four times
higher odds of having attempted suicide in their life than those TGNB respondents who had no

18
experience with school violence (Goldblum et al., 2012). Additionally, a national study of New
Zealand schools showed that TGNB students, compared to their cisgender peers, experienced
more frequent school bullying (OR, 4.5; 95% CI, 2.4 - 8.2; Clark et al., 2014). School violence
experience among TGNB adolescents has also been demonstrated as a correlate of substance use,
with the highest rate of substance use documented among those TGNB young people reporting a
lack of social support (Huebner et al., 2015). Furthermore, the most recent report on school
violence and school climate in the United States by the Gay, Lesbian, and Straight Education
Network (GLSEN) showed that, of all youth in their national study, TGNB youth reported the
most school violence leading authors to the claim that schools in the U.S. are generally hostile
for TGNB students (Kosciw et al., 2018).
Ecological Systems Theory and School Violence Prevention
Researchers interested in the prevention of school violence have used social ecological
systems theory and its associated social ecological model to develop an understanding of
important predictors and correlates of violence in schools (Benbenishty & Astor, 2005;
Benbenishty et al., 2018; Estrada et al., 2014). Urie Bronfenbrenner (1979), the famed
developmental psychologist credited with developing ecological systems theory explained that
human development occurs through the complex, reciprocal interactions that an individual has
with others and the surrounding environment. The social ecological model stemming from this
theory suggests that an interlocking web of social systems interact with one another to influence
the actions, behaviors, experiences and outcomes of individuals (Bronfenbrenner, 1979; Golden
& Earp, 2012; Hong et al., 2011). This theoretical model suggests that individuals’ behaviors are
shaped by the environment in which they are embedded. For adolescents, that environment is
often the place of schooling. The structure and condition of the school, the use of specific school

19
practices (e.g., disciplinary), and the interpersonal relationships between students and teachers
each impact student development and health and influence the level of violence in individual
schools (Thapa et al., 2013).
Though the social ecological model most often places the individual and their
characteristics (e.g., age, sexual orientation, gender) at the center of interlocking and interacting
social systems (Hong et al., 2011), literature on school contexts has utilized the school and its
characteristic factors as central units of examination. In school-based social ecological models,
schools are situated within a broader social environment where extraneous factors are thought to
influence the school outcomes encountered there. These extraneous factors include, for example,
students and their characteristics (e.g., sex, gender, age), neighborhoods, time, history and social
hierarchy (e.g. school boards, and state and federal governing policies). Benbenishty and Astor
(2005) posited this model in their often-cited text, School Violence in Context, where they
illustrate that common social ecological systems impact school variables such as school climate,
which is an important and proximal phenomenon related to students’ ultimately experienced
violence in schools. A social ecological model of school violence outcomes is helpful for
researchers to identify the most salient factors that lead to violence and offer targets for
intervention that disrupt pathways to violence outcomes in school. TGNB students and their
relationship with school organizational variables such as school climate have not been
thoroughly explored, especially the role of gender minority stressors as part of the school climate
(Day et al., 2018).
School Climate: Preventing Violence and Negative Mental Health
School climate is a long-studied phenomenon that is indicative of the overall quality and
character of school life (Cohen et al., 2009). School climate is a phenomenon broader than the

20
experience of one student. Instead, school climate is the aggregate of many individuals’
perceptions of the school setting that include parents, teachers, administrators, students and staff
(Marshall et al., 2015; McGuire et al., 2010). School climate is reflective of the norms, values,
goals, interpersonal relationships, teaching and learning practices and organizational structure of
schools (Thapa et al., 2013). Positive school climates foster healthy youth development by
creating an environment that support people feeling socially, emotionally, and physically safe.
Literature has described the role that negative school climates play in contributing to elevated
rates of school violence, and negative mental health outcomes of students (Benbenishty & Astor,
2005; Benbenishty et al., 2018; Coulter & Rankin, 2017; Thapa et al., 2013). Meta-review of
literature in this area has demonstrated that students’ feelings of safety are foundational to a
positive school climate (Thapa et al., 2013). Deficiencies in safety negatively impact a student’s
ability to thrive in school and are strongly predictive of a student’s likelihood to encounter
school violence.
Transgender and Gender Nonbinary Students and School Climate
TGNB students encounter more violence in schools, are truant, and report more negative
perceptions of school climate relative to cisgender peers (Clark et al., 2014; Day et al., 2018;
Toomey et al., 2012). As of yet, only few evidence-based factors that are known to correlate with
positive school climates for TGNB adolescents have been identified (Day et al., 2018; Kosciw et
al., 2016; Kosciw et al., 2018; Russell et al., 2016; Wernick et al., 2017). The current dialogue on
how to best foster positive school climate for TGNB (as well as LGB) adolescents suggests a
number of important factors thought to be associated with increased perceptions of safety,
reduced school violence encounters, and better mental health. In one of the first research studies
of rural TGNB students De Pedro, Lynch, & Esqueda (2018) highlighted factors documented in

21
existing literature and non-academic reports that are thought to be supportive of LGBT students.
They are, i.) school-based support groups and clubs specific to LGBT students (e.g., gay straight
alliances or GSAs) (Seelman, Forge, Walls, & Bridges, 2015), ii.) teacher and peer intervention
in incidents of bullying and school violence (Wernick et al., 2013, 2014), iii.) promotion and
implementation of enumerated anti-bullying and school violence policies on the basis of one’s
actual or perceived gender identity and sexual orientation which provide direct and immediate
protection to students as well as institutional power to educators to enforce protective policy
(Russell et al., 2016), iv.) the depiction of LGBT people and their experiences in classroom
curriculum across content areas (De Pedro et al., 2016), and v.) availability of LGBT-specific
resources on campus such as access to LGBT attentive sexual and mental health counseling
(Kosciw et al., 2018). The following section reviews these factors as they relate to TGNB
students’ school-based behavioral experiences.
School-Based Support Groups and Clubs Specific to LGBT Students
GSAs have been documented in research to contribute to overall positive school climate
for LGBT adolescents, though the results are somewhat mixed (Gower et al., 2018; Hazel, 2019;
Seelman et al., 2015). GSAs are thought to promote students’ access to supportive and safe
adults (Kosciw et al., 2018) and correlate with increases in student reported self-esteem (Russell
et al., 2011). However, research has also shown that the presence of a GSA alone does not
contribute to improved climate for all LGBT students in schools. One study demonstrated that
GSAs were not associated with improved connectedness to school for LGBT adolescents
(Seelman et al., 2015). This study showed that the characteristics of schools where a GSA was
present (i.e., their size, activity, visibility, financial support and adult involvement), and
individuals’ participation in those GSAs that explained improved perceptions of school climate

22
among LGBT youth (Seelman et al., 2015). This research suggests that GSAs with strong
support from teachers and school administration are likely to be the most effective supports for
LGBT students. In one case, GSAs were shown to have a negative impact on the safety of LGBT
students; a study of rural schools in CA found that LGBT students reported less safety when their
school had a GSA (De Pedro et al., 2018). Those schools embedded in communities that offer
overall limited access to basic LGBT-focused resources and support such as LGBT community
centers, social services and affirming and LGBT-informed populaces may lead to students
feeling less safe regardless of GSA presence (i.e., students in these environments likely
encounter more minority stress). Furthermore, GSAs may be formed by LGBT students and their
advocates in response to pre-existing discriminatory environments, possibly explaining the
finding that GSAs have not been associated with more safety in rural contexts. Ultimately, more
research is needed on the impact of GSAs and on TGNB students’ perceptions of school climate.
Supportive Teachers and Peers in Schools
Gender minority stress theory posits that supportive others, such as supportive peers,
parents and other adults likely provide a strong moderating impact on the negative effects of
environmental and internalized chronic stress on the behavioral health outcomes of TGNB
adolescents (Hendricks & Testa, 2012; Meyer, 2003). Literature with TGNB adolescents has
begun to demonstrate this relationship (Marshall et al., 2015; Simons et al., 2013). In multiple
qualitative studies with TGNB youth, self-advocacy in tandem with supportive individuals in
educational settings (e.g., instructors willing to address students by their chosen names, and to
work with students to keep them protected in schools) were identified as primary factors that
supported the resiliency of these youth (Singh, 2013; Singh et al., 2014). Another study showed
that students’ psychological evaluations of themselves as positive was significantly associated

23
with their reports of the presence of a trusted adult in their school (β = .19, p ≤ .001), and reports
of teachers’ use of biased anti-LGBT language (β = -.11, p ≤ .001; Dessel, Kulick, Wernick &
Sullivan, 2017). Also, social support in the form of adult and peer intervention in harassment was
found to have a strong relationship on LGBT students’ reported perceptions of safety in rural
schools (De Pedro et al., 2018). Supportive adults with specific knowledge on the needs and
experiences of LGBT adolescents including knowledge on human gender and sexuality diversity
likely have positive impacts on the safety of TGNB youth. Furthermore, supportive adults and
peers beget more supportive adults and peers in the context of individual schools. Observed peer
and teacher intervention in sexual and gender minority-based bullying increases the overall
likelihood that students will intervene in future biased-based bullying (Wernick et al., 2013,
2014).
Enumerated Anti-Bullying and School Violence Policies
School policies that explicitly protect students from violence and harassment based upon
their gender identity or sexual orientation, either perceived or actual, are important positive
school climate promoting factors conducive to LGBT adolescents’ positive developmental health
(Russell et al., 2016). A recent national report of the Gay, Lesbian, and Straight Education
Network (GLSEN) on school climate revealed that, although a majority of students in the
country do have at least one supportive policy protective of LGBT students as a whole, only
12.6% of LGBT students are aware that these policies exist (Kosciw et al., 2018). Further, this
study demonstrated that only about 10% of students were aware of any policy or guideline
explicitly supportive of TGNB students (Kosciw et al., 2018). The demonstrated gap between
existing policies and student, teacher and parent awareness of protective policies illustrates the
reality that policies in and of themselves do not offer protection to students without individuals’

24
awareness and readiness to act on written policies (Orr & Baum, 2015). Evidence is promising
however that with explicit and comprehensive policies in schools, LGBT youth can be protected
from violence. For example, GLSEN showed that LGBT students in schools with comprehensive
protective policies on gender identity and sexual orientation were less likely to experience sexual
and gender minority-targeted verbal slurs, were more likely to report that staff were supportive
by intervening in incidences of verbal and physical violence and by reporting greater
connectedness to adults in schools (Kosciw et al., 2018). Further, one researcher demonstrated
that in schools where TGNB students felt safe accessing bathrooms that matched their gender
identity, they were more likely to have increased self-esteem and stronger academic achievement
(Wernick et al., 2017).
Inclusive Curricula and Resources.
GLSEN’s national report also provided estimates of the prevalence and impact of
inclusive curricular resources on the school climate experience of LGBT youth. About one fifth
of LGBT students in this national sample reported being taught positive representations of LGBT
people, history and/or events in their schools, with a similar proportion reporting that they had
been explicitly taught negative content on LGBT people (Kosciw et al., 2018). These statistics
are consequential, students in schools with positive representations and access to LGBT specific
resources such as comprehensive sexual health education attentive to human sexual and gender
diversity were more connected to their schools, reported less verbal and physical victimization,
and among other positive indicators of positive school climate, performed more strongly on their
coursework than those students who did not report representations of LGBT people in their
learning (Kosciw et al., 2018).

25
The impact of the above-listed school climate related factors on improving the safety and
wellbeing of TGNB students requires further examination. Recent research has demonstrated that
only a minority of schools systematically implement these evidence-based factors thought to
promote positive school climate for LGBT students (Green et al., 2018). Researchers suggest that
this may be in large part due to the cultural and socio-political context of many geographic
regions in the United States that may impede the implementation of the specified sexual and
gender minority specific policies and supportive practices. The widespread lack of
implementation of these factors serves to obfuscate current knowledge on the impact that these
factors may have on the schooling, violence and mental health experiences of TGNB students.
Further, though a body of literature does exist examining important school climate and school
violence related factors of LGBT students as a whole, this research often conflates gender
identity and sexual orientation by combining these students and not enrolling or analyzing
TGNB students experiences comprehensively by their subgroup gender identities and sexual
orientations (Frohard-Dourlent, 2016; Frohard-Dourlent et al., 2017). TGNB adolescents have
unique developmental trajectories to that of their sexual identity minority peers and more
research examining their school-based experiences are necessary (Day et al., 2018; Green et al.,
2018; Kosciw et al., 2016; Kosciw et al., 2018; Marshall, 2017; McGuire et al., 2010).
Gender Minority Stress and the Social Ecological Environment of Schools
This dissertation utilizes the social-ecological model of school violence and the gender
minority stress framework to fulfil six specific aims and respond to four research questions (see
Chapter 1, pp.4) that develop preventionists’ understanding of the prevalence of TGNB
adolescents school-based victimization, uncover relevant factors correlated with these negative
school-based experiences (i.e., negative mental health outcomes, indicators of school climate,

26
and supportive others in the schooling process), and describe how this stress as well as support
are experienced in schools using regional, state and national data.

27
Figure 2.1. The Gender Minority Stress Model Adapted from Meyer (2003) and Testa et al.
(2015).

Gender Minority
Identity/
Transgender
Identity
Mental & Physical
Health Outcomes
(e.g., suicidal
ideation)
Circumstances in
the Environment:
e.g.,
positive/negative
school climate
Coping
Distal Stressors:
Gender-related
Discrimination,
Gender-related
Rejection,
Gender-related
Victimization
Non-affirmation of
Gender Identity
Proximal Stressors:
Internalized
Transphobia
Negative
Expectations
Concealment
Social Support
(e.g., supportive
other)

28
Chapter 3. (Study 1): School Violence, and School Climate: The Experience of
Transgender and Gender nonbinary Students

Abstract
Purpose: Descriptive data on the school-based experiences of transgender and gender nonbinary
(TGNB) students is limited, especially in state-wide representative public health data. The
purpose of this study is to examine school violence experiences and perceptions of school
climate among TGNB adolescents in relation to their cisgender (i.e., not TGNB) peers.
Methods: The Healthy Kids Colorado Survey was collected using a two-stage stratified
clustered sampling design at two years, 2015 (N = 15,970) and 2017 (N = 47,146). Weighted
logistic regression models were used to examine for significant differences by gender identity in
regard to reports of school violence and perceptions of school climate while adjusting for
sociodemographic characteristics including urbanicity.
Results: 1.6% of adolescents reported that their gender identity was TGNB with an additional
1.4% reporting that they were questioning their gender identity. In adjusted models, TGNB
adolescents reported experiencing more school violence, feeling less safe at school, participating
less frequently in extracurricular activities, and not feeling that completing school is important
compared to their peers regardless of urbanicity.
Conclusions: School professionals need to address high levels of violence and poor perceptions
of school climate experienced by TGNB young people relative to their cisgender peers that we
found in our sample.
Key words: School Violence, School Climate, TGNB Youth, Gender Minority Stress
Implications and Contributions Statement: TGNB students report more violence in school
and less positive school climates than their cisgender peers in robust representative state-wide

29
data. School professionals and advocates of TGNB and all young people need to simultaneously
reduce violence TGNB students encounter in school and develop affirmative school
environments for these students.

30
School Violence, and School Climate: The Experience of Transgender and Gender
Nonbinary Students
Transgender and gender nonbinary (hereafter TGNB) individuals have gender identities
and expressions that differ from those socially expected of them based on their sex assigned at
birth (The GenIUSS Group, 2014). Gender identity is one’s internal sense of gender, and gender
expression is the external expression of one’s gender identity. TGNB individuals experience
elevated rates of violence that begin early in their lives and persist throughout their lifetimes
(Stotzer, 2009). Nearly 90% of TGNB people encounter violence in society due to their minority
gender identity that includes extreme forms of physical violence and even murder (Stotzer, 2009,
2017; Wirtz et al., 2018). Violence encountered by TGNB adults is correlated with adult mental
illness including suicidal ideation, anxiety and depression, and elevated HIV risk taking behavior
(Cook-Daniels & Munson, 2010; Heintz & Melendez, 2006; Klemmer et al., 2018; Testa et al.,
2012).
Research is needed on the experiences of violence encountered by TGNB young people
across social institutions so that the etiology and impact of violence on TGNB peoples’ lives can
be prevented starting early in life (Wirtz et al., 2018). One particularly important context relevant
to most all youth and adolescents is the schooling environment. Violence encountered in
adolescence can impact trajectories of mental and physical health throughout the life course
(Olsen et al., 2014; Sawyer et al., 2012) and adolescents often encounter violence and stress in
their schooling environments (Benbenishty et al., 2018; Olsen et al., 2014), which has a negative
impact on the mental health and overall wellbeing of many groups of youth including cisgender
(i.e., not TGNB) general populations and cisgender sexual minorities (D’Augelli et al., 2002;
Estrada et al., 2014; Lester et al., 2017). There is a relatively small amount of research on TGNB

31
adolescents compared with cisgender peers and developing an understanding of TGNB young
peoples’ experiences is an important first step for health professionals to create early life
interventions [Day et al., 2018; IOM (Institute of Medicine), 2012]. Thus, more research is
needed to understand the schooling experiences (i.e., school violence and perceptions of school
climate) of TGNB students.
Research, including a systematic review of school climate literature, has illustrated the
role that schools with positive climates have on improving students’ connection to school,
feelings of safety and their mental and physical wellbeing (Thapa et al., 2013). Schools with
positive climates are characterized in part by students reporting greater feelings of safety, and
that their studies are important and meaningful (e.g., that they think finishing school is
important). Limited research about TGNB adolescents’ perceptions of school environments
suggest that TGNB students report lower perceptions of safety and positive school environment
relative to their peers (Day et al., 2018; De Pedro & Esqueda, 2017; Wernick et al., 2017). For
example, one of the first studies to use representative state-wide data that included gender
identity, the California Healthy Kids Survey (CHKS), found that TGNB youth had higher odds
of reporting homophobic bullying, gender-based bullying, and general victimization (e.g.,
physical and verbal assault) when compared with their cisgender peers (Day et al., 2018).
Further, Hatchel and Marx (2018) used the same data to show that for TGNB students, reports of
a positive school climate (e.g., feeling like one belongs in their school) mediate the relationship
between school-based victimization and elevated substance use. In all, there is emerging
evidence that school violence and victimization, as well as perceptions of a positive school
climate are important risk and protective factors for TGNB youth, however, more study of these

32
factors is important to establish their prevalence with a view to informing policies and
interventions to address relevant issues.
Gender Minority Stress Framework
The gender minority stress framework has largely been used to explain the prevalence of
negative behavioral health experiences of TGNB people across the life span (Gamarel et al.,
2014; Hendricks & Testa, 2012). The gender minority stress framework suggests that TGNB
people, due to their stigmatized gender identities and expressions, are targeted for harassment,
violence and discrimination. This targeting ranges from micro-insults and gender identity-based
microaggression (Chang & Chung, 2015) to physical victimization and even murder (Dinno,
2017; Stotzer, 2017). These negative experiences create a chronic burden of stress and
internalized expectations that one will encounter continued violence. Ultimately, this burden of
violence and internalized stress impact individuals’ functioning, contributing to negative
behavioral health (e.g., suicide ideation, and suicide attempt) and risk-taking behavior as forms
of maladaptive coping (Testa et al., 2017). This framework is particularly helpful to understand
the connection between structural level stress perpetrated by and within contextual environments
(e.g., schooling places) and the impact environmental stress places on the experiences and
behavioral health outcomes of TGNB young people.
There is scant peer-reviewed literature that examines school violence and school climate
reports among TGNB students using, large representative data. The magnitude of gender identity-
related disparities in school-based outcomes is unknown due to a deficiency in studies that include
measures of gender identity (Day et al., 2018; Toomey et al., 2018). The present study capitalized
on a rare opportunity to use state-level cross sectional data from a midland state collected at
multiple years to address the following four aims and single sub-aim:

33
Main Aims
1. To estimate prevalence of violence (i.e., school and bullying violence) among in-school
TGNB adolescents.
2. To document perceptions of school climate among in-school TGNB adolescents.
3. To examine if TGNB students are more likely to report violence (i.e., school and bullying
violence) compared to cisgender adolescents controlling for demographic characteristics
(i.e., age, reported sex, racial and ethnic identity, and sexual orientation).
4. To examine if TGNB students are less likely to report positive school climate compared
to cisgender adolescents controlling for demographic characteristics (i.e., age, reported
sex, racial and ethnic identity, and sexual orientation).
Sub-aim
Literature on TGNB young people’s experiences has been largely focused on mainly
liberal coastal samples in the United States, while central and rural dwelling TGNB young
people’s experiences have been overlooked (De Pedro et al., 2018; Fisher et al., 2014; Warren et
al., 2015). Therefore, research is needed to understand if urbanicity is an important factor in
explaining TGNB young people’s reports of school violence and perceptions of school climate.
1. To examine if adolescents’ school urbanicity (i.e., rural or urban regional location)
impacts TGNB adolescents’ reports of violence (i.e., school and bullying violence) and
perceptions of school climate.
A more nuanced understanding of TGNB adolescents’ perceptions of school climate, and
experiences of school violence are needed to support educators and other advocates of youth in
making schools safe and affirming for all students.

34
Methods
Procedures
The Healthy Kids Colorado Survey (HKCS) is a biennial statewide survey conducted in
the state of Colorado [Community Epidemiology and Program Evaluation Group (CEPEG),
2015, 2017]. HKCS is administered via a multi-site collaboration between the Colorado
Department of Education, the Office of Behavioral Health at the Colorado Department of Human
Services, and the Colorado Department of Public Health and Environment (CDPHE) in high
schools (grades 9 – 12). Most questions in the HKCS are based on the Youth Risk Behavior
Survey (YRBS) from the Centers for Disease Control and Prevention (CDC) (CDC et al., 2013;
CEPEG, 2015, 2017). Data for the current analysis are from the 2015 (N = 15,970) and 2017 (N
= 47,146) administrations of HKCS, which were the first two survey administrations in which
gender identity was assessed. HKCS uses a two-module survey approach. Each survey
administration year, two modules (i.e., modules A and B) are used with only some overlapping
questions, allowing researchers to ask more questions of the sample as a whole with a decreased
burden on individual survey respondents.
For both administration years, a two-stage stratified clustered sampling design was
utilized. In the first stage, a list of all Colorado public high schools was obtained from the
Colorado Department of Education, and a stratified sample was selected by survey
administrators following CDC guidelines (CDC et al., 2013). For the second stage, the classroom
sampling frame included each school’s classrooms in a required subject or all classrooms during
a particular period of the school day. Classrooms within each school were sorted by grade, then
alphabetically by teacher last name, and classrooms with fewer than 10 students were combined
with neighboring classes. Ineligible classes included special education, online classes, and

35
classrooms where all or most students did not speak English or Spanish. Classrooms were then
selected using random numbers provided by CDC.
Recruitment and approval occurred at multiple levels: state, district, school,
parent/guardian and student. After approval by three state-wide agencies was received, each
superintendent whose district included a selected school was asked to participate, and once
consent was obtained, each principal of a selected school was contacted for participation.
Parental consent was obtained via letters sent home at least two weeks before survey
administration. Teachers administering the survey read the written instructions aloud to students,
and the same instructions were presented in writing at the beginning of the survey, informing
students that their participation was voluntary and anonymous. No personally identifying
information was collected. In 2015, the high school response rate was 64.1%, and the student
response rate was 72.6%. The overall response rate was 46.5%. In 2017, the high school
response rate was 81%, and the student response rate was 73% with an overall response rate of
59%. The total response rates for the 2015 and 2017 national YRBS was similar to the HKCS at
46.5% and 60% respectively (Kann et al., 2016, 2018). Survey weights were created to account
for differences in the sample and school population, sampling design, modular questions, and
non-participation and non-response (For information on survey weight creation, see: CEPEG,
2015, 2017).
Measures
School violence
School violence was measured with items that assessed for, over the last month, having
brought a weapon to campus and having skipped school due to a concern for one’s safety.
Having been in a physical fight, having been injured or threatened with a weapon on school

36
grounds, and having experienced any bullying (in person and/or cyberbullying) over the last year
was also assessed.
School climate
School Climate was assessed using three items that asked if adolescents participated in
extracurricular activities, felt safe at school, and felt that finishing high school was important.
These questions were modular and were not asked of every survey respondent. The two
questions, one on extracurricular activity participation and the other on feelings of safety
appeared on roughly half of administered surveys in 2015. These two questions appeared on all
administered surveys in 2017. The question asking if finishing high school was important
appeared on roughly half of administered surveys in both administration years 2015 and 2017.
Sociodemographic characteristics
Sociodemographic characteristics included age, reported sex, grade level, racial and
ethnic identity, sexual orientation, and gender identity. Gender identity items for each year first
stated that TGNB people are those whose sex at birth does not match the way they think or feel
about their gender and then asked, “are you transgender?” Response options included “No, I am
not transgender,” “Yes, I am transgender,” “I am not sure if I am transgender,” and “I do not
know what this question is asking.” In 2015, respondents could report if they were either a
transgender boy, a transgender girl, or gender nonbinary. In 2017, this option did not exist as
only the option, “Yes, I am transgender” was available as a response option. Therefore, in the
combined dataset, all respondents in 2015 who indicated being a transgender boy, transgender
girl, or gender nonbinary were coded into the single category of TGNB (variable categories:
Cisgender, TGNB, questioning gender identity and did not understand the question).

37
Respondent urbanicity
Respondent urbanicity, that is if the participating student’s school was in an urban, rural
or mixed environment was determined by the State of Colorado’s 21 health statistics regions.
Only one health statistic region is of mixed urban and rural urbanicity. For those regions where
insufficient samples of adolescents participated to develop a regional sampling weight (15.9% of
sampled students), an urbanicity observation was coded as unknown. The reference group for
this item was set as urban.
Analysis
To fulfill aims one and two, descriptive statistics were conducted for study variables by
gender identity. Then, to fulfill aims three and four, first univariate logistic regression was used
to examine for significant relationships between gender identity and adolescent characteristics
(i.e., age, sex, racial and ethnic identity, and sexual orientation) with each of the study outcomes
(i.e., school violence and school climate). Gender identity and covariates were then included in
adjusted logistic regression models for final statewide estimates. Statistical significance was
assessed at p < .05, and we report odds ratios with 95% confidence intervals. To fulfill sub-aim
one urbanicity was then included in each model to examine for changes in estimates of the
relationship between gender identity and study outcomes. All statistical analyses were carried out
using Stata version 14 and accounted for the complex clustered sample survey design (StataCorp,
2015). (For more information on YRBS and HKCS data analysis collection see: Centers for
Disease Control and Prevention (CDC) et al., 2013; CEPEG, 2015, 2017; Clayton et al., 2016).
Results
Sociodemographic characteristics, school violence and school climate indicators are
summarized in Table 1. Nearly 5% of the sample reported their gender as something other than

38
cisgender, with 1.6% reporting a TGNB gender identity and 1.4% reporting questioning their
gender identity. Half of the sample (50.9%) reported their sex as male. Each grade level 9-12
was nearly equally represented, and the majority of the sample was White (57.3%), with Latinos
as the second largest racial and ethnic group (27.6%). Over 10% of the sample reported a sexual
orientation other than heterosexual, with nearly 2.7% of the sample reporting their sexual
orientation as bisexual, 3.4% questioning their sexuality, and 1.8% identifying as gay or lesbian.
As for reports of school violence, TGNB youth reported more violence across all
assessed items than their cisgender peers including for example, having carried a weapon on
campus (21.4% to 3.5%; p < .001), having skipped school due to safety concerns (32.1% to
4.8%; p < .001), and being threatened or injured with a weapon on school grounds (33.5% to
5.3%; p < .001). Further, compared to cisgender peers, TGNB youth reported less frequently that
they participated in extracurricular activities (58.4% to 69.5%; p < .001), felt safe at school
(60.1% to 91.5%; p < .001), and felt finishing school was important (82.9% to 98%; p < .001).
Adjusted logistic regression results for school violence outcomes are summarized in
Table 2. TGNB youth were between 5.5 to nearly 6 times more likely to report bringing a
weapon on campus (aOR: 5.6, 95% CI: 3.5, 8.8), to skip school due to safety concerns (aOR: 6.0,
95% CI: 4.1, 8.7), and to be threatened or injured by a weapon on campus (aOR: 5.5, 95% CI:
4.3, 7.1) compared with their cisgender student peers. Further, TGNB students were more likely
to report physical fighting (aOR: 2.3, 95% CI: 1.8, 3.1) and bullying (aOR: 3.4, 95% CI: 2.7, 4.2)
when compared to cisgender students. Youth questioning their gender identity and those who did
not understand the gender identity question also had greater odds of almost all assessed school
violence items compared to their cisgender peers in the study.

39
Table 3 summarizes the results of the adjusted logistic regression models for indicators of
school climate. Compared to cisgender youth in the study, TGNB youth had 40% lower odds of
participating in extracurricular activities (aOR: 0.6, 95% CI: 0.4, 1.0), and nearly 80% lower
odds of feeling safe at school (aOR: 0.2, 95% CI: 0.1, 0.4) and reporting that finishing school is
important (aOR: 0.2, 95% CI: 0.1, 0.4). Further, compared to cisgender students, youth who
questioned their gender identity and those who did not understand the gender identity question
had lower odds of reporting each positive school climate indicator except in one instance (i.e.,
youth that questioned their gender identity did not differ with cisgender youth in terms of
extracurricular participation).
The results of analyses for sub-aim one which adjusted the previous models by including
urbanicity are summarized in Table 4. The associations reported above in regard to school
violence and school climate perceptions held the same for TGNB youth in our final adjusted
models indicated that they experience more school violence and poorer perceptions of school
climate relative to cisgender peers. For school violence outcomes, urbanicity was related to
weapon carrying, physical fighting and bullying. Compared with urban students, rural students
had 2.2 times greater odds of having carried a weapon to campus (95% CI: 1.8, 2.7), and slightly
higher odds of fighting (aOR: 1.1, 95% CI: 1.0, 1.2) and bullying (aOR: 1.1, 95% CI:1.1, 1.2).
Overall, urbanicity had few significant relationships on reports of school climate in our models.
Compared with urban students, those in rural areas had greater odds of participating in
extracurricular activity (aOR: 1.2, 95% CI: 1.1, 1.4), and 29% lower odds of reporting feeling
safe at school (aOR: 0.8, 95% CI: 0.7, 1.0). Furthermore, sociodemographic covariates were
found to influence reports of school violence and perceptions of climate. For example all racial
and ethnic minorities but Asians were more likely to have been in a physical fight than their

40
White peers, African American youth felt less safe at school than their white peers (aOR: 1.6,
95% CI: 1.3, 2.0), and sexual minorities (i.e., LGB and Questioning students) consistently
reported significantly more violence and poorer perceptions of school climate than heterosexual
students in our data.
Discussion
We found that compared with cisgender adolescent peers in the state of Colorado, youth
reporting a TGNB gender identity, youth questioning their gender identity, and those who did not
understand questions about gender identity reported more school violence (i.e., having carried a
weapon to school, skipping school due to concerns for their safety, having been threatened or
injured at school by a weapon, fighting at school, and having been bullied). Further, TGNB
youth in our study were less likely than cisgender students to participate in extracurricular
activities, to report feeing safe at school, and to share that they felt finishing school was
important. The results of these studies corroborate findings that have emerged in other regionally
focused studies that TGNB young people face a high burden of violence and diminished
connection to their school places (Clark et al., 2014; Day et al., 2018; De Pedro et al., 2018;
Hatchel & Marx, 2018).
This study contributes to the standing literature base in a number of ways. This study
establishes prevalence estimates of school violence and perceptions of school climate for TGNB
young people and those questioning their gender identity in relation to their cisgender peers
using two large relatively recent diverse representative samples of high school students. Further,
this study used state-wide data from multiple time points across the state of Colorado, a midland
region often overlooked relative to coastal urban areas of the United States (Fisher et al., 2014).
Thus, this study used one of a few datasets from the central region of the United States to

41
establish state-wide prevalence estimates of TGNB youths’ schooling experiences with
adjustments made for geographic location.
In line with recent work, we found that TGNB adolescents reported greater proportions of
school violence compared with their peers (Johns et al., 2019; Pedro & Esqueda, 2017). For
example, a recent short report of the CDC using YRBS data from states and districts across the
nation showed that 23.8% of TGNB young people reported being threatened or injured by a
weapon, and 34.6% reported bullying, each significantly greater in comparison with cisgender
peers (Johns et al., 2019). Further, in a regionally focused study utilizing data from the CHKS,
De Pedro and Esqueda (2017) found that for TGNB students, 26.9% had been in a physical fight,
15.8% had brought a weapon to school, and 20.7% had been threatened with a weapon. Again,
for each case, these findings were significantly greater when compared with non-TGNB peers.
Our study adds depth to existing data in its disaggregation of gender identity categories and
shows that youth who question their gender identity have higher likelihood than their cisgender
peers to experience school violence including reporting having carried a weapon, having skipped
school, having been threatened or injured with a weapon, and having been bullied, but not having
been in a physical fight.
School climate has been studied among TGNB adolescents to a lesser degree than school
violence, though, our data in regard to indicators of school climate aligns with emerging reports.
In the above-mentioned report by Johns and colleagues (2019), 27% of TGNB students reported
skipping school due to a safety concern which is similar to our findings that 32.2% of TGNB
students skipped school due to a safety concern. Additionally, in another study utilizing CHKS
data, TGNB students reported lower perceived levels of positive school climate in comparison
with cisgender students (Day et al., 2018). Our study aligns with this California-based finding

42
given that TGNB youth and those questioning their gender identity in our study had between 72-
79% lower odds of reporting that they felt finishing school was important relative to their
cisgender peers. Again, our study adds depth to existing literature because we are able to report
on the perceptions of school climate among those adolescents who questioned their gender
identity. While youth questioning their gender had no significant difference from their peers in
regard to participating in extracurricular activities, they more frequently felt unsafe at school,
and were more likely to report that they did not feel finishing school was important. Thus, our
data show that like those youth who identify as TGNB, those in a process of gender identity
questioning also are not reporting positive perceptions of their schooling.
We were surprised to see that youth in rural environments reported more school violence
and reported feeling less safe than their urban dwelling counterparts. Model adjustments for
urbanicity changed little the magnitude of school violence and climate perception reports of
TGNB students. Fisher and colleagues (2014) found almost no statistical differences in the
experiences of rural LGBTQ people in comparison with urban counterparts across the state of
Nebraska. They report that regional culture, for example the relative presence or absence of
LGBTQ-targeted stigma in a given locale, trumped population density alone when examining
correlates of negative behavioral health experiences for LGBTQ people. Garnering an
understanding of gender minority stressors and their impact on TGNB students across
geographic locations in the United States remains important and our findings also demonstrate
that, while urbanicity is an important factor in school-based experiences of violence and safety,
urbanicity itself is not the most important variable in understanding TGNB students’ schooling
experiences (De Pedro et al., 2018; Fisher et al., 2014). This sentiment is echoed in general
literature on schools and urbanicity (i.e., research not focused on LGBTQ students), which has

43
reported on differences between urban and rural schools. While ideas that rural schools in some
parts of the United States do not perform as well as those in metropolitan regions remain, this is
not always the case in reported data (McCracken & Barcinas, 1991; Reeves & Bylund, 2005) and
other factors (e.g., student, school and community characteristics) in addition to geography are
important to consider when evaluating schools.
Finally, there were notable results among study covariates, especially in regard to sex and
race or ethnicity. Students reporting female sex were more likely to experience non-physical
forms of school violence than males including having skipped school due to safety concerns, and
bullying. These sex-based disparities have been widely corroborated in school-based violence
and climate literature globally and in the United States (Astor & Benbenishty, 2019). In part
these disparities are indicative of widely held social beliefs and norms, for example that
boys/men are to be instrumental and aggressive and are therefore more likely to rely upon
physical fighting than girls/women. As for racial or ethnic differences, all racial and ethnic
minorities reported less bullying than whites. Further, African American students reported more
frequently that they did not feel safe at school relative to white students. Research on racial and
ethnic differences in school violence and school climate experiences have been more mixed
(Astor & Benbenishty, 2019; Connell et al. 2015). Racial and ethnic disparities in school-based
data are likely more dependent on other factors including culture, immigration, assimilation, and
socioeconomic status.
Study Implications
There is a growing consensus that the best school environments are those that foster
social and emotional learning (SEL) in addition to traditional academic learning (Capp et al.,
2018). To foster SEL as well as academics, schools must build settings that are physically and

44
emotionally safe for all students (National Commission on Social, Emotional, & Academic
Development, 2019). Students in schools with positive climates that address their social and
emotional learning are associated with positive health and academic success for students (Cohen
et al., 2009; Day et al., 2018; Thapa et al., 2013). Allied school-based professionals (e.g.,
administrators, educators, school social workers, and school nurses) must address the elevated
violence reported by TGNB adolescents and work to create schooling experiences where these
young people feel affirmed, safe and that their schooling is important (Cicero & Wesp, 2017;
McGuire et al., 2010). Focused improvement of school climate perceptions and reduction in
school violence for TGNB students may be one way that school professionals can increase the
health, academic success and overall wellbeing of this minority group. Additionally, though
examining the school violence and school climate experiences of students by sex and race or
ethnicity were not specific aims of the present study, these encountered disparities in our data
hold important implications. All students, including TGNB students, deserve access to equitable
and healthy schooling experiences and observed disparities by sex and race or ethnicity
demonstrate that school-places are sites where students across sociodemographic categories can
and do experience school violence and poor connections to their schools. Researchers suspect
that elevated proportions of negative behavioral experiences amongst any one given group are
related to poor school climate and student outcomes as a whole (Benbenishty et al., 2018;
Connell et al. 2015). Thus, there is an urgent need for allied education and health professionals to
promote positive school environments for the health and success of TGNB and all students.
School-based research has established that, while individually focused interventions and
support are essential for overall student wellbeing, systematic and environment-based
intervention approaches are necessary to improve the wellbeing of all students and to address

45
school violence and negative school climate (Bonell et al., 2013; Olsen et al., 2014). The gender
minority stress theory and its associated framework which is specific to the experienced
behavioral health and wellbeing of TGNB populations is helpful in guiding educational
professionals in creating more salubrious and affirming environments (Hendricks & Testa,
2012). For example, this model suggests that gender-identity based harassment and
discrimination, whether perpetrated by individuals (e.g., being bullied by peers) or structurally
(e.g., bathroom policies that bar TGNB youth from using bathrooms) become a chronic burden
on these youth which makes them feel unsafe, depletes their positive coping resources and can
lead to detrimental behavioral outcomes (e.g., weapon carrying at school). Recent literature has
demonstrated that when schools possess supportive resources such as Gay Straight Student
Alliances, have teachers and staff trained in gender-inclusive schooling (e.g., through trainings
such as QuERI; see Smith & Payne, 2016), and enumerated LGBTQ-protective policies, TGNB
students report less bullying, more peer support, and more teacher support compared with
schools that do not have these resources available (Day, Fish, Grossman & Russell, 2019; Smith
& Payne, 2016). Structural intervention has therefore been shown to be promising in available
school-based data, and the study of such intervention is indicated. Furthermore, though our study
consists of a high school-aged sample, structural interventions to create TGNB affirming school-
places should not occur in high schools alone, but also in elementary and middle school settings
as research has demonstrated that stigmatizing binary gender norms are practiced and adopted by
youth as early as in elementary school settings (Kosciw et al., 2018; Smith & Payne, 2016;
Thorne, 1993).

46
Limitations and Future Directions
More robust empirical research is needed to establish the most effective intervention
targets in schools to support TGNB youth. Given the gender minority stress model’s reliance on
a temporal ordering of events (i.e., that gender identity-based stigma and discrimination precedes
and precipitates negative outcomes), longitudinal school-based studies of TGNB adolescents’
experiences in the school place that examine for changes in structural-level stressors and
associated academic, school violence, school climate, and health outcomes are important and
needed next steps. Analyzed data in the present study comes from two cross-sectional surveys.
This method offered a large robust sample of youth with sufficient sample size to analyze
outcomes with attention to gender identity but is not longitudinal and cannot establish
temporality of events. Furthermore, structural interventions may have been in place in a number
of the schools in our sample, however information on structural supports were not collected.
Future research should attempt to compare structural supports implemented between schools.
Further, gender identity labels are fluid and many (e.g., nonbinary, genderqueer, agender)
(The GenIUSS Group, 2014) and though we were able to offer some disaggregation of gender
identity labels (i.e., TGNB, and questioning gender identity) our study is limited in that it did not
assess for gender identity with more nuance due to limitations of combining two survey
administrations. Best practices for assessing gender identity explain that assigned sex at birth is
an important item, however our questionnaire asked only “what is your sex?” which does not
allow us to make assumptions about an individual’s gender identity (i.e., as transmasculine or
transfeminine) (The GenIUSS Group, 2014). Future work should accurately assess for gender
identity so that a more complete understanding of the impact of multiple gender identities and
their risk and resilience profiles can be understood broadly across youth populations. Full

47
information was not available regarding regional location for all students, nor were all questions
asked of all study participants (e.g., school climate options were only provided to a subset of the
whole sample). More robust empirical research is needed to understand the school-based
experiences of TGNB young people across various geographic localities including those living in
rural and urban areas (De Pedro et al., 2018; Fisher et al., 2014). Finally, we found that many
sociodemographic characteristics including racial and ethnic minority status and sexual
orientation were significantly related to school violence and school climate perceptions. Future
research should attend to intersectionality by examining how disparities manifest among TGNB
students by various sexual orientations and racial and ethnic identities. This underscores the need
for large robust datasets which enroll sufficiently sized numbers of TGNB students of color.
Conclusion
In 2015 and 2017, TGNB adolescents in high schools in the state of Colorado reported
more school violence and poorer perceptions of their school climates than did their cisgender
peers accounting for other sociodemographic factors. Allied education professionals including
teachers, school social workers and administrators must address the burden of violence and
disconnection that TGNB young people reported in our study. This is especially important given
evidence that violence toward any one group in school can have school-wide implications on
climate, academic success and mental health of all adolescents in a given school (Astor &
Benbenishty, 2018; Benbenishty et al., 2018). As a remedy, education professionals should
continue to seek understanding of TGNB students’ school-based experiences through research.
In particular it is important to develop a fuller understanding of promising potentially effective
interventions including training LGBTQ-affirmative adults in schools, promoting LGBTQ

48
student coalitions, and promulgating LGBTQ-specific anti-harassment policies; (Heck, 2015;
Kosciw et al., 2018; Smith & Payne, 2016).

49
Table 3.1. Weighted Sample Characteristics by Gender Identity, 2015 and 2017.
Cisgender Transgender or
Gender Nonbinary
Questioning
gender identity
Did not
understand
question
Sample Demographics* Weighted % (SE) Weighted % (SE) Weighted % (SE) Weighted % (SE)
Gender Identity (N = 58,503) 95.11 (.002) 1.66 (.001) 1.45 (.001) 1.78 (.001)
Reported Sex (N = 58,030)
Male 50.94 (.006) 45.01 (.042) 39.04 (.041) 67.07 (.030)
Female 49.06 (.006) 54.99 (.042) 60.96 (.041) 32.93 (.030)
Grade Level (N = 58,245)
9th grade 26.36 (.009) 21.36 (.025) 29.29 (.029) 35.07 (.027)
10th grade 25.42 (.007) 29.52 (.034) 24.23 (.030) 24.74 (.023)
11th grade 24.23 (.007) 21.83 (.036) 22.49 (.032) 19.34 (.018)
12th grade 23.79 (.006) 20.98 (.027) 20.37 (.030) 18.78 (.025)
Ungraded 0.20 (.001) 6.30 (.019) 3.62 (.012) 2.08 (.008)
Racial and Ethnic Identity (N = 57,834)
American Indian or Alaska Native 0.70 (.0007) 1.51 (.006) 0.98 (.002) 1.49 (.004)
Asian 3.45 (.002) 5.42 (.014) 2.23 (.007) 5.84 (.022)
Black or African American 4.60 (.005) 4.26 (.009) 5.70 (.021) 6.67 (.016)
Native Hawaiian or Pacific Islander 0.21 (.0004) 0.52 (.003) 0.41 (.001) 0.29 (.001)
White 57.33 (.018) 45.81 (.051) 54.01 (.034) 36.37 (.038)
Latino 27.69 (.014) 19.84 (.020) 26.10 (.035) 38.39 (3.68)
Multiracial 6.03 (.005) 22.65 (.043) 10.56 (.021) 10.96 (.013)
Sexual Orientation (N = 57,951)
Straight 87.85 (.004) 23.38 (.040) 28.29 (.035) 71.00 (.034)
Gay or Lesbian 1.81 (.001) 27.97 (.032) 8.27 (.017) 2.09 (.007)
Bisexual 6.93 (.003) 27.01 (.030) 32.67 (.027) 3.02 (.007)
Questioning 3.41 (.001) 21.64 (.028) 30.77 (.030) 23.88 (.030)
Urbanicity (N = 58,503)
Urban 57.04 (.047) 59.17 (.063) 49.3 (.068) 53.37 (.051)
Rural 11.35 (.009) 9.96 (.015) 10.6 (.016) 17.72 (.021)
Mixed 0.68 (.002) 0.45 (.003) 0.85 (.003) 1.60 (.006)
Unknown 30.9 (.051) 30.42 (.065) 39.25 (.078) 27.31 (.056)

50
School Violence
Carried Weapon on School Grounds, Last
Month (N = 57,675)
3.53 (.002) 21.40 (.024) 12.82 (.021) 8.53 (.014)
Skip School Due to Safety Concerns, Last
Month (N = 57,833)
4.80 (.002) 32.17 (.029) 16.13 (.017) 12.64 (.018)
Threatened or Injured with Weapon on School
Grounds, Last year (N = 57,791)
5.30 (.003) 33.56 (.027) 16.40 (.025) 11.90 (.015)
In a Physical Fight, Last Year (N =57,720) 18.32 (.005) 40.55 (.027) 27.75 (.036) 28.81 (.021)
Bullied, Last Year (N = 57,608) 23.72 (.005) 59.16 (.024) 39.87 (.028) 31.42 (.028)
Indicators of School Climate
Participated in Extracurricular Activities, Last
Year (N = 48,144)
69.48 (.007) 58.42 (.051) 64.68 (.034) 52.09 (.043)
Feels Safe at School (N = 48,538) 91.50 (.005) 60.12 (.050) 80.17 (.033) 80.65 (.029)
Finishing School is Important (N = 27,681) 98.05 (.001) 82.96 (.034) 89.88 (.026) 91.33 (.023)
* weighted percentages are reported column-wise

51
Table 3.2. Adjusted Logistic Regression Results, Gender Identity and School Violence, 2015 and 2017.
Carried Weapon A # Skip School Due to
Safety Concerns A
Threatened or
Injured with
Weapon B #
In a Physical Fight
B
Bullied B &
(N = 56,110) (N = 56,265) (N =56,224) (N = 56,152) (N = 56,059)
AOR (95% CI) AOR (95% CI) AOR (95% CI) AOR (95% CI) AOR (95% CI)
Gender Identity
Cisgender Ref Ref Ref Ref Ref
TGNB 5.57 (3.53, 8.77)*** 5.96 (4.09, 8.66)*** 5.51 (4.29, 7.07)*** 2.33 (1.78, 3.06)*** 3.38 (2.70, 4.24)***
Questioning 3.26 (2.19, 4.85)*** 2.26 (1.61, 3.17)*** 2.09 (1.40, 3.11)*** 1.40 (0.93, 2.10) 1.51 (1.13, 2.00)**
Did not understand
question
1.94 (1.28, 2.95)** 2.01 (1.44, 2.81)*** 2.00 (1.42, 2.84)*** 1.49 (1.19, 1.86)*** 1.81 (1.44, 2.27)***
Reported sex
Male reported sex Ref Ref Ref Ref Ref
Female reported sex 0.31 (0.27, 0.36)*** 1.24 (1.07, 1.43)** 0.55 (0.48, 0.63)*** 0.43 (0.39, 0.47)*** 1.75 (1.62, 1.89)***
Age 1.13 (1.07, 1.20)*** 0.96 (0.90, 1.02) 0.94 (0.88, 1.00) 0.89 (0.85, 0.93)*** 0.88 (0.84, 0.92)***
Race or Ethnicity
White Ref Ref Ref Ref Ref
Asian 0.78 (0.43, 1.41) 0.94 (0.61, 1.44) 0.82 (0.54, 1.25) 0.71 (0.49, 1.05) 0.63 (0.51, 0.78)***
African American 0.97 (0.55, 1.70) 1.31 (0.89, 1.93) 1.17 (.73, 1.86) 1.60 (1.29, 1.97)*** 0.53 (0.42, 0.66)***
Latino 0.75 (0.61, 0.93)** 1.48 (1.25, 1.75)*** 1.12 (.94, 1.34) 1.27 (1.17, 1.38)*** 0.66 (0.59, 0.73)***
Multiracial & others 1.28 (0.98, 1.68) 1.40 (1.11, 1.77)** 1.70 (1.42, 2.05)*** 1.75 (1.53, 2.01)*** 0.86 (0.75, 0.98)*
Sexual Orientation
Heterosexual Ref Ref Ref Ref Ref
Gay or Lesbian 2.05 (1.43, 2.93)*** 1.53 (1.14, 2.06)** 2.04 (1.51, 2.75)*** 1.30 (0.91, 1.86) 1.77 (1.43, 2.19)***
Bisexual 1.85 (1.41, 2.44)*** 2.22 (1.79, 2.76)*** 2.13 (1.76, 2.57)*** 2.12 (1.69, 1.65)*** 1.98 (1.73, 2.26)***
Questioning 1.78 (1.38, 2.31)*** 2.30 (1.62, 3.26)*** 1.91 (1.52, 2.39)*** 1.26 (1.05, 1.50)* 1.30 (1.06, 1.58)*
* p < .05, **p < .01, ***p < .001;
Ref = Reference category, TGNB = Transgender or Gender Nonbinary;
A Last Month;
B Last Year;
# On school grounds;
& At school in person and/or online (i.e., cyberbullied)

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Table 3.3. Adjusted Logistic Regression Results, Gender Identity and School Climate 2015 &
2017, HKCS.
Participated in
Extracurricular
Activities A
Feels Safe at
School
Finishing School is
Important
(N = 46,926) % (N = 47,320) % (N = 26,969) %
AOR (95% CI) AOR (95% CI) AOR (95% CI)
Gender Identity
Cisgender Ref Ref Ref
TGNB 0.59 (0.35, 0.99)* 0.22 (0.14, 0.36)*** 0.21 (0.11, 0.41)***
Questioning 0.81 (0.61, 1.07) 0.55 (0.35, 0.87)* 0.28 (0.12, 0.62)**
Did not understand question 0.51 (0.35, 0.75)*** 0.51 (0.34, 0.79)** 0.38 (0.20, 0.75)**
Reported sex
Male reported sex Ref Ref Ref
Female reported Sex 1.14 (1.02, 1.27)* 1.11 (0.94, 1.30) 2.68 (1.99, 3.59)***
Age 0.94 (0.89, 0.99)* 1.07 (1.01, 1.13)* 0.88 (0.73, 1.06)
Race or Ethnicity
White Ref Ref Ref
Asian 0.80 (0.62, 1.03) 1.08 (0.77, 1.52) 0.86 (0.38, 0.93)
African American 0.67 (0.50, 0.89)** 0.56 (0.38, 0.81)** 0.62 (0.31, 1.24)
Latino 0.50 (0.43, 0.58)*** 0.80 (0.68, 0.95)* 0.72 (0.43, 1.18
Multiracial & others 0.64 (0.55, 0.73)*** 0.90 (0.64, 1.25) 0.79 (0.42, 1.48)
Sexual Orientation
Heterosexual Ref Ref Ref
Gay or Lesbian 0.99 (0.72, 1.35) 0.52 (0.37, 0.73)*** 0.43 (0.25, 0.73)**
Bisexual 0.76 (0.64, 0.89)*** 0.52 (0.39, 0.69)*** 0.27 (0.16, 0.48)***
Questioning 0.92 (0.66, 1.28) 0.51 (0.38, 0.67)*** 0.26 (0.14, 0.48)***
* p < .05, **p < .01, ***p < .001;
A Last Year;
Ref = Reference category, TGNB = Transgender or Gender Nonbinary;
%Note: School climate indicators were modular survey items and not assessed among the full
sample. Therefore, sample size for each item varies. Population estimates are weighted
accordingly to the number of adolescents who received each item.

53
Table 3.4. Logistic Regression Results Adjusted for Urbanicity, 2015 & 2017, HKCS.
Carried Weapon A # Skip School Due to
Safety Concerns A
Threatened or
Injured with
Weapon B #
In a Physical Fight
B
Bullied B &
(N = 56,110) (N = 56,265) (N = 56,224) (N = 56,152) (N = 56,059)
AOR (95% CI) AOR (95% CI) AOR (95% CI) AOR (95% CI) AOR (95% CI)
Gender Identity
Cisgender Ref Ref Ref Ref Ref
TGNB 5.60 (3.62, 8.65)*** 5.97 (4.09, 8.70)*** 5.50 (4.29, 7.06)*** 2.33 (1.78, 3.06)*** 3.38 (2.70, 4.23)***
Questioning gender 3.26 (2.17, 4.90)*** 2.24 (1.59, 3.15)*** 2.07 (1.37, 3.10)*** 1.41 (.94, 2.11) 1.50 (1.12, 1.99)**
Did not understand
question
1.78 (1.16, 2.72)** 2.02 (1.45, 2.81)*** 1.99 (1.41, 2.81)*** 1.47 (1.17, 1.84)*** 1.78 (1.42, 2.25)***
Reported sex
Male reported sex Ref Ref Ref Ref Ref
Female reported sex 0.31 (0.27, 0.37)*** 1.23 (1.07, 1.42)** 0.55 (0.48, 0.62)*** 0.43 (0.39, 0.47)*** 1.75 (1.61, 1.89)***
Age 1.12 (1.06, 1.19)*** 0.96 (0.93, 1.02) 0.94 (0.88, 1.00) 0.89 (0.85, .093)*** 0.88 (0.84, 0.92)***
Race or Ethnicity
White Ref Ref Ref Ref Ref
Asian 0.85 (0.47, 1.55) 0.95 (0.62, 1.46) 0.85 (0.55, 1.30) 0.72 (0.49, 1.05) 0.65 (0.52, 0.79)***
African American 1.08 (0.60, 1.95) 1.23 (0.92, 1.92) 1.20 (0.76, 1.90) 1.61 (1.31, 1.97)*** 0.54 (0.43, 0.67)***
Latino 0.74 (0.60, 0.91)** 1.50 (1.27, 1.76)*** 1.14 (0.96, 1.35) 1.26 (1.16, 1.37)*** 0.66 (0.60, 0.73)***
Multiracial & others 1.32 (1.03, 1.70)* 1.40 (1.11, 1.78)** 1.71 (1.42, 2.06)*** 1.76 (1.54, 2.02)*** 0.86 (0.75, 0.98)*
Sexual Orientation
Heterosexual Ref Ref Ref Ref Ref
Gay or Lesbian 2.21 (1.54, 3.18)*** 1.52 (1.13, 2.04)** 2.04 (1.51, 2.76)*** 1.32 (0.93, 1.87) 1.78 (1.43, 1.24)***
Bisexual 1.90 (1.46, 2.54)*** 2.22 (1.79, 2.75)*** 2.14 (1.77, 2.58)*** 2.13 (1.70, 2.68)*** 1.99 (1.74, 2.27)***
Questioning 1.80 (1.39, 2.33)*** 2.30 (1.62, 3.28)*** 1.92 (1.53, 2.42)*** 1.25 (1.05, 1.50)** 1.30 (1.06, 1.59)**
Urbanicity
Urban Ref Ref Ref Ref Ref
Rural 2.18 (1.77, 2.70)*** 0.99 (0.85, 1.16) 1.11 (0.94, 1.32) 1.12 (1.02, 1.24)* 1.14 (1.05, 1.24)***
Mixed 3.01 (1.35, 6.67)** 1.03 (0.61, 1.74) 1.46 (0.74, 2.87) 1.41 (1.14, 1.74)*** 1.35 (1.04, 1.76)*
Unknown 0.72 (0.54, 0.96)* 1.15 (0.94, 1.39) 1.15 (0.88, 1.50) .87 (0.74, 1.02) 1.06 (0.93, 1.21)
Participated in
Extracurricular
Activities B
Feels Safe at School Finishing School is
Important

(N = 46,926) % (N = 47,320) % (N = 26,969) %

54
AOR (95% CI) AOR (95% CI) AOR (95% CI)
Gender Identity
Cisgender Ref Ref Ref
TGNB 0.58 (0.34, 0.98)* 0.22 (0.14, 0.36)*** 0.21 (0.11, 0.41)***
Questioning 0.80 (0.61, 1.06) 0.55 (0.35, 0.87)** 0.28 (0.12, 0.62)**
Did not understand
question
0.50 (0.34, 0.73)*** 0.52 (0.34, .080)** 0.39 (0.20, 0.76)**
Female Reported Sex
Male reported sex Ref Ref Ref
Female reported sex 1.14 (1.02, 1.27)* 1.11 (.94, 1.30) 2.68 (2.00, 3.60)***
Age 0.94 (0.89, 0.99)* 1.07 (1.01, 1.13)* 0.88 (0.73, 1.06)
Race or Ethnicity
White Ref Ref Ref
Asian 0.83 (0.64, 1.07) 1.06 (.75, 1.50) 0.84 (0.37, 1.88)
African American 0.69 (0.52, 0.91)* 0.54 (0.38, 0.79)*** 0.61 (0.30, 1.23)
Latino 0.51 (0.44, .058)*** 0.80 (0.68, 0.96)* 0.71 (0.43, 1.17)
Multiracial & others 0.65 (0.56, 0.75)*** 0.89 (0.64, 1.25) 0.78 (0.41, 1.46)
Sexual Orientation
Heterosexual Ref Ref Ref
Gay or Lesbian 1.00 (0.72, 1.37) 0.52 (0.37, 0.73)*** 0.42 (0.25, 0.73)**
Bisexual 0.76 (0.64, 0.89)*** 0.52 (0.39, 0.69)*** 0.27 (0.16, 0.48)***
Questioning 0.93 (0.67, 1.29) 0.50 (0.38, 0.67)*** 0.25 (0.14, 0.47)***
Urbanicity
Urban Ref Ref Ref
Rural 1.23 (1.07, 1.40)** 0.81 (0.70, 0.95)* 0.92 (0.70, 1.21)
Mixed 2.15 (0.78, 5.93) 0.87 (0.54, 1.40) 0.31 (0.05, 1.61)
Unknown 1.11 (0.95, 1.28) 1.04 (0.77, 1.41) 0.96 (0.69, 1.33)
* p < .05, **p < .01, ***p < .001;
Ref = Reference category, TGNB = Transgender or Gender Nonbinary;
A Last Month;
B Last Year;
# On school grounds;
& At school in person and/or online (i.e., cyberbullied)
%Note: School climate indicators were modular survey items and not assessed among the full sample. Therefore, sample size for
each item varies. Population estimates are weighted accordingly to the number of adolescents who received each item.

55
Chapter 4. (Study 2): The Mediating Effect of School Stress and Violence on Suicide
Ideation and Attempt Among Transgender and Gender Nonbinary Young People

Abstract
Background: Transgender and gender nonbinary (TGNB) adolescents are at increased risk of
school stress and violence exposure and are more likely to report suicidal ideation, and suicide
attempt compared to their cisgender peers. The association between school environment and
suicide ideation and attempt among TGNB youth and young adults in relation to cisgender peers
requires further exploration.
Method: Young people were recruited from an LGBTQ youth-focused crisis prevention provider
during an 18-month period (September 2015 to April 2017). After provider contact, youth were
transferred to a brief survey of demographic and contact information. Eligible adolescents
[reported non-heterosexual orientation (if TGNB, any sexual orientation eligible), aged 12-24,
and provided consent to participate] were then contacted for survey participation. Survey
questions assessed sociodemographic characteristics, school stress and violence experiences,
suicide ideation severity, and suicide attempt using an adaptation of the Colombia Suicide
Severity Rating scale. Descriptive analyses were followed by two mediation analyses using
logistic and linear regression.
Results: The analytic sample consisted of 263 (44.65%) TGNB respondents and 326 (55.35%)
cisgender respondents with an overall mean age of 17.6 years. TGNB young people reported
greater levels of suicide ideation severity and suicide attempt than their cisgender peers.
Significant relationships were present between gender identity and suicide ideation and suicide
attempt. Mediation analyses showed that reports of school stress and violence attenuated the

56
direct association between gender identity and suicide ideation severity by 25.1%, and between
gender identity and reported suicide attempt by 20.1%.
Major Implications: School environments are an important correlate of the mental health of
TGNB young people. Continued examination of the stress and violence experienced by TGNB
young people is necessary. Reducing stress and violence encountered by TGNB students may be
associated with reduced risk for suicide ideation severity and suicide attempt.
Keywords: Transgender and gender nonbinary; Gender minority stress; School climate; School
violence; Suicidality

57
The Mediating Effect of School Stress and Violence on Suicide Ideation and Attempt
among Transgender and Gender Nonbinary Young People
Transgender and gender nonbinary (TGNB) youth and young adults have gender
identities (i.e., one’s internalized sense of gender) and/or gender expressions (i.e., the way that
one presents their gender through behavior and appearance) different from that expected of them
based on the sex assigned to them at birth (e.g., an individual assigned male sex at birth whose
gender identity and expression are feminine) (The GenIUSS Group, 2014). Gender identity-
based stress and violence in TGNB people’s lives starts early and lasts throughout their lifetimes
(Johns et al., 2019; Stotzer, 2009), and includes daily gender-based microaggressions (e.g., the
use of incorrect gender pronouns) as well as violence such as physical assault and even murder
(Chang & Chung, 2015; Stotzer, 2009, 2017). However, given the importance of adolescence
and young adulthood in determining long-term trajectories of mental health (Sawyer et al.,
2012), more research is needed to understand of the role of stress and violence exposure by
gender identity during this life stage (Griner et al., 2017).
Schools are an important context where youth can encounter stressful and violent
experiences (e.g., social isolation, and feeling physically unsafe) that are associated with
negative mental health and poor health later in life (Cicero & Wesp, 2017; D’haese et al., 2016;
Hatchel & Marx, 2018; Kosciw et al., 2018). While literature describes high levels of suicide
ideation, suicide attempt and school-based violence among TGNB students, there is limited
exploration of the role of the school climate in mediating the relationship between gender
identity and poor mental health. Thus, research that examines the experiences of LGBTQ-
targeted school stress and violence as a mediator of TGNB young people’s mental health is an
important area of inquiry (Day et al., 2018; Hatchel & Marx, 2018). Further, because research

58
has often combined TGNB people with cisgender lesbian, gay, bisexual and queer (LGBQ)
people, studies that disaggregate and discuss differences between these two categories of identity
(i.e., sexual orientation and gender identity) are also needed within school-based literature
(Frohard-Dourlent et al., 2017)
Gender Minority Stress and Negative Mental Health
The elevated observed negative mental health experiences of TGNB people have largely
been attributed to minority stressors. Minority stress theory was first proposed as an explanatory
model to understand the negative health experiences of sexual minorities (i.e, LGBQ people;
Meyer, 2003) and was later adapted to TGNB populations (Testa et al., 2015). Gender minority
stress theory posits that minority stress experienced by TGNB people on the basis of their gender
subjects them to an increased burden of violence and stress in their daily lives. Examples of
gender minority stress include gender identity-based microaggressions, a lack of social support
from friends, teachers, parents, and service providers as well as policies that place stress on
TGNB people (e.g., legislation mandating bathroom use based upon one’s sex assigned at birth)
(Bender-Baird, 2016; Wernick et al., 2017). Homelessness prevalence data provides a poignant
and important example of gender minority stress; TGNB people have 2 times higher odds of
experiencing homelessness compared to the general U.S. populations (Begun & Kattari, 2016).
Further, the odds of experiencing homelessness for visually non-conforming TGNB people
compared with those who are visually conforming is even higher (Begun & Kattari, 2016). These
stressors impact TGNB people on the intrapersonal level by fostering expectations of further
encountering violence and rejection, developing thoughts of internalized self-hatred or
worthlessness, and desires to conceal one’s minority identity to avoid further victimization. In
total, gender minority stressors burden individuals’ coping resources and resiliency, leading to

59
negative mental health outcomes when social support and pride and connection to a community
(e.g., the LGBTQ community) are weak or lacking (Budge et al., 2013).
Suicidal Ideation and Suicide Attempt Among TGNB Adolescents
TGNB individuals experience high levels of suicide ideation and attempt throughout their
lifetime. One of the largest U.S studies conducted of TGNB adults that queried TGNB people
accessing services at over 900 service providers found a lifetime prevalence of suicide attempt of
41%, much higher than the 4.6% prevalence of the general U.S. population (Haas et al., 2014).
Studies from across Canada, the U.S., and Europe have similarly shown that TGNB adults’
lifetime prevalence of suicide attempts are high, with reports of prevalence ranging from 22% to
43% (Bauer et al., 2015).
Estimates of suicidal ideation and attempt among TGNB adolescents are also high
compared with cisgender peers (Reisner et al., 2015). In a recent study of TGNB adolescents by
gender identity utilizing U.S. data, rates of suicide attempt ranged from 27.9% among youth
questioning their gender identity, to over 50% among transmasculine adolescents (Toomey et al.,
2018), rates that far exceed estimates of cisgender adolescent populations (Marshall et al., 2016).
Additionally, the CDC recently reported that nearly 40% of TGNB students made plans to
attempt suicide (i.e., had suicidal ideation) compared with only 10.4% among their cisgender
male peers (Johns et al., 2019). These studies demonstrate a need for continued exploration of
the associations between gender identity and suicide ideation and attempt.
School Stress and Violence, and Suicide Ideation and Attempt
Stress and violence encountered due to an individual’s gender identity in the context of
schools may be associated with increased suicidal ideation and attempt (Whitaker et al., 2016).
For example, a 2018 study showed higher prevalence of suicide ideation and attempts among

60
TGNB youth whose chosen names were not respected across social contexts (i.e., home, school
and work) compared with those whose names were respected (Russell et al., 2018). Research
with sexual minority students (i.e., LGBQ, but not TGNB students) has found that a lack of
connectedness with schools has a positive relationship with suicide ideation and attempt
(Whitaker et al., 2016). The degree to which school-based factors are protective for TGNB
adolescents’ mental health however is not fully known and continued examination of gender
identity-based differences in school stress and violence is needed. In particular, exploration of
the experiences of TGNB youth and young adults of all sexual orientations in relation to
cisgender LGBQ peers for whom more school-based research exists has been indicated (D’haese
et al., 2016).
Protective Factors.
The impact of gender minority stress on suicide ideation and attempt may be mitigated by
the degree of social support received by adolescents (Testa et al., 2015). A number of studies in
the United States and Canada have documented the protective role of supportive others on
negative mental health experiences of TGNB youth as well as LGBQ youth, (Bauer et al., 2015;
Nesmith et al., 1999; Simons et al., 2013; Wilson et al., 2016). Additionally, the most recent
report of the GLSEN (formerly the Gay, Lesbian & Straight Education Network) school climate
survey from the United States suggests that youth who report more supportive educators in their
school also report greater feelings of safety compared to those with few or no supportive
educators (Kosciw et al., 2018). Further, teachers and peers supporting LGBQ students as a
whole creates overall positive school climates (Wernick et al., 2014), however, little research has
examined the role of supportive or unsupportive others (i.e., peers, teachers, administrators,

61
and/or staff members at school) in association with outcomes like suicidal ideation and attempt
for TGNB students (Bauer et al., 2015; Dessel et al., 2017).
School Climate
School climate is the quality and character of a school-place measured through the
presence of teacher and peer support, reports of safety and connectedness to school, and desire to
be at school (Cohen et al., 2009; Freiberg, 1999). Systematic meta-analysis has shown that
school climate is related to health outcomes (Cohen et al., 2009; Freiberg, 1999; Thapa et al.,
2013). In particular, literature has shown that school climate is an important factor that
influences students’ suicide ideation and attempt (Astor & Benbenishty, 2018; Benbenishty et
al., 2018; Freiberg, 1999). For example, in California students’ school climate perceptions were
associated with their suicidal ideation so that students with less favorable perceptions of school
climate had increased levels of suicidal ideation (Benbenishty et al., 2018). The roles of school
climate among TGNB adolescents have been observed in few studies and further research on the
role of the components of school climate in relation with TGNB adolescents’ mental health are
needed (Day et al., 2018).
Specific Aim and Research Question
Existing research has called for further examination of suicide ideation and suicide
attempt among TGNB young people of all sexualities, and their cisgender LGBQ peers (Marshall
et al., 2016). Also, continued research on stressful and unsupportive school climates and their
association with TGNB young peoples’ suicide ideation and suicide attempt is also indicated
(Swanson & Gettinger, 2016). In response, the present study seeks to examine the school
violence and stress reports of TGNB young people and the association of those reports with
suicide ideation and attempt using a U.S. nationally drawn sample of LGBTQ young people

62
accessing services at a suicide-crisis hotline. We have formulated the following research aim and
research questions:
Research Aim:
To document the prevalence and the relationships between LGBTQ-based school stress
and violence experiences, suicide ideation severity and suicide attempt among a sample of young
people seeking help at a suicide-crisis hotline.
Research Question 1:
Do LGBTQ-based school stress and violence experiences mediate the association
between TGNB gender identity and suicide ideation severity in a sample of LGBTQ young
people accessing a suicide-crisis hotline?
Research Question 2:
Do LGBTQ-based school stress and violence experiences mediate the association
between TGNB gender identity and reports of suicide attempt in a sample of LGBTQ young
people accessing a suicide-crisis hotline?
Our aim and research questions follow from the gender minority stress framework
(Figure 1) which posits that structural and intrapersonal stress such as LGBTQ-based school
stress and violence mediate the relationships between suicide ideation severity and suicide
attempt and TGNB identity. Empirical support of school stress and violence as a potential
mediator of TGNB adolescents’ suicide ideation severity and suicide attempt can serve to direct
future school-based research on modifiable factors for improved young people’s mental health.

63
Methods
Participants and Procedures
The current study relied on a national sample of youth (aged 12–24) recruited from an
LGBTQ suicide-crisis hotline provider during an 18-month period (September 2015 to April
2017; for more detailed description of recruitment, see Rhoades et al., 2018). After a crisis
contact with the organization, eligible individuals were transferred to an automated survey of
demographic and contact information assessing age, race and ethnicity, gender identity, sexual
orientation, zip code, and contact information. From those who were referred to the demographic
survey, a total of 2,008 participants were eligible [non-heterosexual identity (if TGNB any
sexual orientation eligible), aged 12-24, and provided consent to participate] and were contacted
for study participation. Because adolescents may have been at high risk for suicide ideation and
suicide attempt given their use of a suicide crisis hotline, all participants went through a
suicidality-assessment before survey participation. Participants received a $15 gift card incentive
for involvement in the study. Overall, 33% of youth referred to the study completed the survey (n
= 657). Sixty-five responses were dropped due to incomplete information on study variables
leaving a total sample of 589 adolescents. Of the 589-person analytic sample, 263 (44.6%)
reported TGNB gender identity. The study was approved by the University of Southern
California institutional review board.
Measures
Demographic characteristics.
Demographic characteristics included age, race and ethnicity, gender identity, and sexual
orientation. In regression analysis, age was a continuous variable. The race and ethnicity item
included six response options (Native American, American Indian, or Alaska Native; Asian or

64
Pacific Islander; Black or African American; White; Latino or Hispanic; and race and ethnicity
not listed here). For analysis, racial and ethnic identity was coded into White (reference), Black
or African American, Latino or Hispanic, and all others. Gender identity was assessed using best
practices for the identification of TGNB adolescents (The GenIUSS Group, 2014). First, youth
were asked what sex they were assigned at birth (i.e., male or female), followed by a question
asking their current gender identity (response options: male, female, transgender male,
transgender female, genderqueer, questioning, don’t know, and gender identity not listed). Those
whose gender identity was different than that socially expected of them given their sex assigned
at birth were identified as TGNB (i.e., all but cisgender males and cisgender females were
categorized as TGNB in a binary variable). Sexual orientation was assessed in one questioning
asking, “what is your sexual orientation?” with nine response options (i.e., gay, lesbian, bisexual,
queer, pansexual, straight, questioning, asexual or sexual orientation not listed). For analysis, this
item was coded as gay and lesbian (reference), bisexual, pansexual and all others. Youth were
also asked if they were currently enrolled in school.
LGBTQ-based school stress and violence.
Experiences of LGBTQ-based school stress and violence were assessed using 13 binary
response items (i.e., yes or no), each in the form of a statement. Examples include, “I have felt
unsafe or threatened in school because I am LGBTQ,” “I have been physically assaulted by
students at school because I am LGBTQ,” and “A teacher or staff at my school is unsupportive
of me because I am LGBTQ.” For analysis, this item was summed for a total continuous count
variable of the number of LGBTQ-based school stress and violence experiences. These 13 items
were developed through thematic analysis of qualitative life history interviews with LGBTQ

65
adolescents and through consultation with sexual minority adolescent health experts using a
Delphi process (for overview of item creation and testing see: Schrager et al., 2018)
Suicide Ideation Severity Scale & Suicide Attempt.
Suicidal ideation severity was measured with items adapted for self-report from the
Columbia-Suicide Severity Rating Scale (C-SSRS) (Posner et al., 2011). Lifetime prevalence
items included were the following five yes or no questions listed in order of severity, “Have you
wished you were dead or wished you could go to sleep and not wake up?” “have you had
thoughts about killing yourself?” “Have you had any thoughts about a way that you might kill
yourself?” “When you had thoughts about killing yourself, did you have some intention (even a
little bit) of acting on them?” and “Have you thought about a specific plan (for example, having a
time or place) to kill yourself?” For the present study, all items were summed into a “worst-
point” severity scale item for suicide ideation ranging on a continuum from no suicide ideation
(0) to suicide plan (5). Respondents score is based on the most severe kind of ideation endorsed.
An adopted C-SSRS item assessed presence of any lifetime suicide attempt in one binary
response question (“Have you ever tried to kill yourself?”).
Analysis
Descriptive statistics were used to examine sample demographic characteristics (i.e.,
sample gender identity, age, sexual orientation, racial and/or ethnic identity, and school
enrollment) by gender identity. Then, LGBTQ-based school stress and violence reports were
examined among each of the 13 reported items by gender identity. A chi-square test of
independence was conducted for each item to determine if TGNB adolescents reported a
significant difference in the proportion of LGBTQ-based school stress and violence relative to
their cisgender peers. Then, reports of LGBTQ-based school stress and violence, the suicide

66
ideation severity scale, and suicide attempt were examined by gender identity. Subsequently,
ordinary least squares (for suicide ideation severity) and logistic regression (for suicide attempt)
were used in two separate mediation analyses following the methodology of Baron and Kenny
(1986) to examine for school stress and violence experiences as a mediator of the relationship
between gender identity and suicide ideation severity and suicide attempt. To start, bivariate
relationships between covariates and suicide ideation severity and suicide attempt were
examined and significant (i.e., p < .05) covariates were placed into mediation models. For each
mediation analysis, first a regression examined for significant correlation between reported
gender identity and suicide-related dependent variable (path C), then for significant correlation
between gender identity and the proposed mediator, LGBTQ-based school stress and violence
(path A). A final regression was used to examine for changes in the association between gender
identity and suicide-related dependent variable in the presence of the hypothesized mediator
(paths B and C’). Nonsignificant covariates were removed from models to achieve the most
parsimonious final estimates. Finally, 5000 bootstrap samples were utilized to obtain 95% bias-
corrected confidence intervals for direct, indirect, and total effects of each mediation model.
Results
Sample demographic characteristics are summarized in Table 1. Just under half of the
sample (44.6%) identified as TGNB. The most reported TGNB gender identity was transgender
male (27.3%), followed by genderqueer (19.7%). The sample’s mean age was 16 years of age
(SD: 3.8). Young people reported diverse sexual orientations. The most frequently reported
sexual orientations were gay and lesbian (39.4%), bisexual (17.1%), and pansexual (17.1%). The
racial and/or ethnic composition was majority White (66.7%), with those reporting one or more

67
racial and/or ethnic identities as the second largest group in the sample (10.3%). Just over four-
fifths of the adolescent and young adult sample reported being currently in school (81.2%).
Reports of LGBTQ-based school stress and violence, suicide ideation severity, and
suicide attempt for the sample are summarized in Table 2. We found significant differences in
reported LGBTQ-based school stress and violence among cisgender and TGNB adolescents. For
all but one experience of stress and violence (i.e., having seen other LGBTQ youth treated badly
at school), TGNB adolescents reported a greater proportion of negative experiences than did
their cisgender peers. For example, while 21.7% of cisgender adolescents reported that they have
felt unsafe or threatened in school because of their LGBTQ identity, more than double that
proportion of TGNB adolescents (45.6%) reported feeling unsafe because of their LGBTQ
identity (X2 = 42.59; p < .001). Also, while over 30% of TGNB students reported being made
fun of because of their LGBTQ identity, less than half that proportion of cisgender adolescents
(14.1%) reported having been made fun of because of their LGBTQ identity (X2 = 31.45; p
< .001). Additionally, 7.3% of cisgender adolescents felt that teachers or staff were unwilling to
stand up for them, while nearly a quarter of TGNB adolescents (25.7%) felt that teachers or staff
would not support them (X2 = 52.98; p < .001). Overall, the mean number of reported LGBTQ-
based school stress and violence experiences for cisgender adolescents in our sample was 2.9
(SD = 2.5), with nearly double that amount among TGNB adolescents (M = 4.5, SD = 3.1)
[t(587) = -6.66, p < .001]. As for suicide ideation severity, cisgender youth had a mean severity
of 2.0 (SD = 2.1), while TGNB participants’ mean severity was 2.4 (SD = 2.0) [t(587) = -254.66,
p = .011]. Nearly one quarter of cisgender adolescents in our sample reported making a suicide
attempt in their lives, while over 40% of TGNB respondents had made an attempt (X2 = 20.67, p
< .001).

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Suicide Ideation Severity. Mediation analyses are summarized in Table 3. Bivariate
analysis showed that sexual orientation was significantly related to suicide ideation severity. In
the first model [Proportion of variance explained (R2) = .02], path C, TGNB gender identity
[standardized coefficient (B) = 0.10, p = .014] was significantly related to suicide ideation
severity. In the subsequent model (R2 = .08), path A, TGNB gender identity (B = 0.28, p ≤ .001)
was also found to be significantly correlated with increased reports of LGBTQ-based school
stress and violence. In the regression model for paths C’ and B (R2 = .02) examining for the
association of TGNB gender identity on suicide ideation severity in the presence of LGBTQ-
based school stress and violence, the association between gender identity and suicide ideation
severity was weakened (B = 0.08, p = .076). LGBTQ-based school stress and violence was
associated with suicide ideation severity in this model (B = 0.10, p ≤ .022) indicating a fully
mediated relationship between gender identity and suicide ideation severity through experiences
of school stress and violence. Sexual orientation was not associated with suicide ideation severity
in the pathway models. The results of our bootstrapping procedures are also summarized in
Table 3. Bootstrap samples with bias corrected confidence intervals demonstrated a significant
indirect effect of gender identity on suicidality through LGBTQ-based school stress and violence
(b = 0.11, 95% CI = 0.019, 0.229). Nearly one-quarter (24.9%) of the effect of gender identity on
elevated rates of suicidality was mediated through LGBTQ-based school stress and violence in
our model.
Suicide Attempt. Bivariate analysis showed that suicide attempt was associated with
enrollment in school. School enrollment was therefore included in mediation modeling. The
logistic regression model for path C showed that TGNB gender identity was related to reported
suicide attempt (aOR = 2.1, p < .001). Current enrollment in school was correlated with reduced

69
likelihood of reporting suicide attempt (aOR = 0.62, p = 0.037). The OLS regression model for
Path A (R2 = .07) showed that TGNB gender identity was associated with school stress and
violence experience (B = 0.26, p < .001). Current school enrollment was not associated with the
proposed mediator in this model. In our last model for paths B and C’, TGNB gender identity
maintained a significant relationship with reported suicide attempt (aOR = 1.89, p < .001).
Reports of school stress and violence were associated with suicide attempt as well (aOR = 1.11,
p < .001) suggesting partial mediation of the relationship between gender identity and suicide
attempt through school stress and violence. The indirect effect was significant (b = 0.4, 95% CI =
0.017, 0.075), one fifth of the relationship of gender identity with suicide attempt was mediated
through school stress and violence.
Discussion
The results of our study align with existing research that documents high rates of gender
minority stress in schools, suicide ideation, and suicide attempt for TGNB young people relative
to cisgender peers (Clark et al., 2014; Day et al., 2018; Johns et al., 2019; Kosciw et al., 2018).
The suicide attempt prevalence in our sample was 41.8% for TGNB respondents, similar to
prevalence estimates reported elsewhere (Johns, 2019; Toomey et al., 2018). This is an
alarmingly high prevalence of suicide attempt and requires immediate attention at all levels
including through policy and practice intervention. It is a main finding of the present study that
school stress and violence, categorized by a lack of supportive others and fears of violence and
rejection mediated the association between gender identity and suicide ideation and attempt by
25.1% and 20.1% respectively. Our results seem to uphold a gender minority stress theoretical
perspective and can be interpreted using its associated stress and resilience framework (Testa et
al., 2015).

70
Practice and Policy Implications
Teachers, administrators and school-support professionals such as school social workers
and counselors can intervene to create more affirmative, safe and supportive schools for TGNB
students by addressing gender minority stress present in their school places. A number of
methods to address gender minority stressors have been highlighted in existing research
including training, enumerated LGBTQ anti-bullying policies, and LGBTQ student coalitions
(Day et al., 2018; Kosciw et al., 2018).
LGBTQ Student Affirmation Training
TGNB students in our sample often reported that teachers did not stand up for them, were
not supportive of them, and that their experiences were not reflected at all in their curricula.
Educators and school-support professionals (e.g., school social workers and school counselors)
therefore can begin to address the lack of TGNB affirmative knowledge, skills and behaviors
among adults in the school place by providing training. Teachers themselves have documented
that at times they are unaware of the needs of TGNB students, are unable to support them, and
even hold anti-TGNB sentiments (Smith & Payne, 2016; Swanson & Gettinger, 2016; Zotti et
al., 2019). Further, teachers are less likely to take on TGNB-supportive roles than to report that
taking on those roles is important (Swanson & Gettinger, 2016). School support professionals are
particularly well suited to educate their school-based colleagues (i.e., teachers and
administrators) on TGNB-affirmative knowledge, skills and behaviors through training (Hong &
Garbarino, 2012; Whitman et al., 2007). Such training can focus on detailing human gender and
sexuality diversity, the prevalence of violence and negative mental health experienced by TGNB
students, and the important role that teachers can have on these youths’ wellbeing. Importantly,
such training can teach how to interrupt individual cases of LGBTQ bullying observed by

71
teachers at school (for more on training see: Case & Meier, 2014). Teacher observance of their
peers interrupting and delegitimizing LGBTQ-targeted bullying predicted the same behavior in
study respondents (Zotti et al., 2019). Therefore, training even a few teachers may be impactful
for individual schools.
Enumerated LGBTQ Anti-bullying Policies
TGNB students also reported feeling unsafe and being bullied at school because of their
identities. Enumerated anti-bullying and harassment policies that protect students based on
gender identity have been widely established as important supports of TGNB students, and may
help to address students reports in this study (Day et al., 2019; Kosciw et al., 2018; Russell et al.,
2016; Seelman & Walker, 2018; Swanson & Gettinger, 2016). Enumerated policies that protect
students based on their gender identity create a foundation for teachers and staff to create safe
and protective school climates and send a message to everyone at school that the needs of TGNB
youth are legally defensible. Teachers are more comfortable and confident intervening to protect
bullied and/or harassed LGBTQ students and have a more accurate understanding of bullying
problems at their schools when such policies exist (Russell et al., 2010, 2016). Additionally,
quasi-experimental research that examined enumerated protective policies, bullying and suicide
ideation and attempt at the state-level showed that states with such policies see LGBTQ youth
report less bullying (Seelman & Walker, 2018). Enumerated policies may be a helpful
intervention to reduce the rate of stress and violence we observed among TGNB students in our
study.
LGBTQ-Affirmative Coalitions
Student-run and teacher-supported GSAs are likely important school-based supports for
TGNB students. In systematic meta-analysis GSA presence in school was significantly

72
associated with reduced levels of LGBTQ students’ reports of peer bullying victimization (Marx
& Kettrey, 2016). Further, LGBTQ students report less bullying, more peer support and more
teacher support in the presence of both GSAs and enumerated protective policies (Day et al.,
2019). Thus, while GSAs and enumerated protective policy are distinctly helpful, they are in
tandem mutually beneficial (Day et al., 2019). Less research has examined the specific role of
GSAs in the school-based stress and violence, and mental health experiences of TGNB students.
School belonging mediates the relationship between TGNB students’ bullying victimization and
likelihood to report substance use (Hatchel & Marx, 2018). GSAs increase LGBTQ students’
school belonging (Heck et al., 2013),
Limitations
Our study is not without limitations. For one, our data is a cross-sectional examination
and we cannot determine causation between study variables. Also, our sample was majority
female reported sex at birth (68.4%) and white, especially among the TGNB group of
respondents for whom 70.7% reported white racial or ethnic identity. Thus, our findings cannot
be generalized to all TGNB young people. Other research accessing samples through suicide
prevention service providers have also had higher prevalence of female respondents which
suggests that they may access services at a higher rate (King et al., 2003), or that providers
should do more to engage males in need of suicide crisis services. Additionally, accessing
respondents through a suicide-crisis hotline is itself a limitation and inferences should be made
about the school-based experiences of all TGNB students with caution. Additionally, in all
mediation models the amount of variance explained was fairly modest suggesting that other
factors beyond LGBTQ-based school stress and violence experiences are associated with suicide
ideation and attempt.

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Future Research
Evidence on the effectiveness of school-based interventions is limited and much more
research is needed. For example, comprehensive studies of the role of teacher and staff trainings
on LGBTQ affirmation are few and more research is needed (Swanson & Gettinger, 2016; Zotti
et al., 2019). Additionally, the role of supportive policies on supporting TGNB student health are
in need of further examination. Existing research has not been able to show a relationship
between general state-level protective policies and suicide ideation and attempt among LGBTQ
students (Seelman & Walker, 2018). More research is necessary on the impact of enumerated
protective policies at various levels (e.g., intra- and inter-district) on TGNB students’ school and
mental health experiences. As for GSAs, future research should examine the impact of GSAs for
TGNB students’ specifically, including potential association with reduced peer victimization,
social isolation and suicide ideation and attempt given that much research on GSAs to date
aggregates the experiences of LGBTQ students (Heck et al., 2013; Marx & Kettrey, 2016).
Additionally, examination of GSAs as an effective modality for delivering school climate change
and mental health interventions to protect against TGNB adolescent suicide and promote an
affirmative school place are needed (Heck, 2015). While research has existed on GSAs for at
least two decades, more rigorous examinations of GSAs impact on TGNB students specifically
are needed throughout the U.S. Finally, future school-based research that examines suicide
ideation and attempt with more individuals of many gender identities (e.g., transgender men,
transgender women, and male assigned sex at birth nonbinary people) and of diverse racial
composition are needed (Kattari et al., 2019).

74
Conclusion
The present study demonstrates that TGNB young people accessing suicide crisis
prevention services experience elevated levels of LGBTQ-based school stress and violence
compared to their cisgender sexual minority peers accessing the same service. Our study
demonstrates the extent to which unsupportive schooling environments mediate the association
between gender identity and reporting elevated suicide ideation severity and between reported
attempt of suicide. Professionals charged with the care of TGNB young people (e.g., teachers,
administrators, and school social workers) should work toward developing gender-affirmative
schools characterized by perceptions of safety, belonging and adult and peer support by TGNB
students. Promising avenues to achieve this end are through training of school-based
professionals, ensuring that enumerated protective policy is adopted, and that student coalitions
that normalize TNGB students’ experiences are available in schools.

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Table 4.1. Sample Characteristics (N = 589).
Total Cisgender TGNB
N (%) N (%) N (%)
Gender Identity 326 (55.35) 263 (44.65)
Male 132 (40.49) 18 (6.84)
Female 194 (59.51) 12 (4.56)
Transgender Male -- 72 (27.38)
Transgender Female -- 18 (6.84)
Genderqueer -- 52 (19.77)
Questioning -- 35 (13.31)
Don’t Know -- 12 (4.56)
Identity Not Listed -- 42 (15.97)
Refuse to Answer -- 2 (0.76)
Age
12 to 14 years old 100 (16.98) 53 (16.26) 47 (17.87)
15 to 18 years old 279 (47.37) 151 (56.32) 128 (48.67)
19 to 21 years old 117 (19.86) 72 (22.09) 45 (17.11)
22 to 24 years old 93 (15.79) 50 (15.34) 43 (16.35)
Sexual Orientation
Gay & Lesbian 232 (39.39) 165 (50.61) 67 (25.48)
Bisexual 101 (17.15) 71 (21.78) 30 (11.41)
Pansexual 101 (17.15) 34 (10.43) 67 (25.48)
Other sexual orientation 155 (26.32) 56 (17.18) 99 (37.64)
Racial and/or Ethnic Identity
White 393 (66.72) 207 (63.50) 186 (70.72)
Black or African American 40 (6.79) 26 (7.98) 14 (5.32)
Latino or Hispanic 55 (9.34) 33 (10.12) 22 (8.37)
Multiracial 61 (10.36) 37 (11.35) 24 (9.13)
Others 40 (6.79) 23 (7.06) 17 (6.46)
Currently in School 479 (81.32) 276 (84.66) 203 (77.19)
Note: Percentages reported column-wise excluding the first row (i.e., gender identity), which is
reported row-wise. Transgender or Gender Nonbinary = TGNB

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Table 4.2. LGBTQ-based School Stress and Violence, Suicidal Ideation, and Suicide Attempt Among Sample (N = 589).
Total Cisgender TGNB
N (%) N (%) N (%) X2 p-value
LGBTQ-based School Stress and Violence
Because I am LGBTQ, I have:

Felt unsafe or threatened in school 191 (32.43) 71 (21.78) 120 (45.63) 42.59 < 0.001
Had to leave or change schools 53 (9.00) 17 (5.21) 36 (13.69) 15.19 < 0.001
Felt isolated or alone at school 274 (46.52) 124 (38.04) 150 (57.03) 21.12 < 0.001
Lost friendships since coming out 159 (26.99) 74 (22.70) 85 (32.23) 6.83 0.033
Physically assaulted by students at school 49 (8.32) 15 (4.60) 34 (12.93) 13.78 < 0.001
Other youth refuse to do school activities with me 78 (12.24) 34 (10.43) 44 (16.73) 8.07 0.081
Seen other LGBTQ youth treated badly at my school. 311 (52.80) 165 (50.62) 146 (55.51) 1.41 0.494
It's hard to be an LGBTQ person at my school. 207 (25.14) 101 (30.98) 106 (40.30) 9.02 0.011
Other students make fun of me for being LGBTQ 129 (21.90) 46 (14.11) 83 (31.56) 31.45 < 0.001
My school does not protect LGBTQ students 157 (26.66) 77 (23.62) 80 (30.42) 18.65 < 0.001
A teacher or staff at my school is unsupportive of me 87 (14.77) 30 (9.20) 57 (21.67) 25.05 < 0.001
A teacher or staff at my school is unwilling to stand up for me 89 (15.11) 24 (7.36) 65 (24.71) 52.98 < 0.001
In school, LGBTQ topics are not covered at all in classes 359 (60.95) 180 (55.21) 179 (68.06) 17.61 < 0.001
Suicide Ideation Severity Scale Items 16.31 0.006
No ideation 204 (34.63) 135 (41.41) 69 (26.24)
Passive ideation 87 (14.77) 42 (12.88) 45 (17.11)
Active ideation 41 (6.96) 17 (5.21) 24 (9.13)
Method 40 (6.79) 21 (6.44) 19 (7.22)
Intent 63 (10.70) 32 (9.82) 31 (11.79)
Plan 154 (25.15) 79 (24.23) 75 (28.52)
Reported Suicide Attempt 189 (32.09) 79 (24.23) 110 (41.83) 20.67 < .001
M (SD) M (SD) M (SD) t-test p-value
Number School Stress and Violence Experiences 3.63 (2.93) 2.93 (2.51) 4.50 (3.19) -6.66 < .001
Suicide Ideation Severity Scale 2.22 (2.08) 2.03 (2.10) 2.46 (2.03) -2.54 .011
Transgender or Gender Nonbinary (TGNB) gender identity;
Lesbian, Gay, Bisexual, Transgender and/or Queer (LGBTQ);
*P ≤ .05, **P ≤ .01, ***P ≤ .001

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Table 4.3. Mediation Analysis Results (N = 589).
Suicide Ideation Severity
Path C; Dependent Variable: Suicide
Ideation Severity Scale
b B SE P-value
Gender Identity
Cisgender Ref Ref Ref Ref
TGNB 0.450 0.107 0.183 0.014
Sexual Orientation
Gay & Lesbian Ref Ref Ref Ref
Bisexual 0.178 0.032 0.246 0.470
Pansexual 0.034 0.061 0.256 0.185
All other sexual orientations -0.224 -0.047 0.224 0.317
Path A; Dependent Variable: School
Stress and Violence
b B SE P-value
Gender Identity
Cisgender Ref Ref Ref Ref
TGNB 1.636 0.276 0.251 < 0.001
Sexual Orientation
Gay & Lesbian Ref Ref Ref Ref
Bisexual -0.742 -0.095 0.337 0.028
Pansexual -0.262 -0.033 0.350 0.453
All other sexual orientations -0.520 -0.077 0.306 0.090
Paths B and C’; Dependent Variable:
Suicide Ideation Severity Scale
b B SE P-value
Gender Identity
Cisgender Ref Ref Ref Ref
TGNB 0.337 0.080 0.189 0.076
School Stress and Violence 0.069 .097 0.030 0.022
Sexual Orientation
Gay & Lesbian Ref Ref Ref Ref
Bisexual 0.229 0.041 0.246 0.353
Pansexual 0.358 0.064 0.255 0.161
All other sexual orientations -0.188 -0.039 0.223 0.400
Bootstrap Results A b SE 95% CI
Indirect Effect 0.113 0.052 0.019, 0.229
Direct Effect 0.337 0.190 -0.040, 0.696
Total Effect 0.450 0.182 0.082, 0.797
Suicide Attempt
Path C; Dependent Variable: Suicide
Attempt*
aOR SE P-value
Gender Identity
Cisgender Ref Ref Ref
TGNB 2.19 0.39 < .001
Currently in school
No Ref Ref Ref
Yes 0.62 0.13 0.037

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Path A; Dependent Variable: School
Stress and Violence
b B SE P-value
Gender Identity
Cisgender Ref Ref Ref Ref
TGNB 1.540 0.260 0.236 < 0.001
Currently in school
No Ref Ref Ref Ref
Yes -0.290 -0.038 0.302 0.338
Paths B and C’; Dependent Variable:
Suicide Attempt*
aOR SE P-value
Gender Identity
Cisgender Ref Ref Ref
TGNB 1.89 0.35 < 0.001
School Stress and Violence 1.11 0.03 < 0.001
Currently in school
No Ref Ref Ref
Yes 0.64 0.14 0.052
Bootstrap Results A b SE 95% CI
Indirect Effect 0.042 0.014 0.017, 0.075
Direct Effect 0.168 0.048 0.073, 0.261
Total Effect 0.211 0.046 0.118, 0.299
Transgender or Gender Nonbinary (TGNB)
Reference (Ref)
*Logistic Regression
A Statistical significance determined by 95% bias-corrected confidence intervals (CI) based on
5,000 bootstrap samples.

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Figure 4.1. The Role of LGBTQ-based School Stress and Violence in Mediating the Association
between Minority Gender Identity and Suicidality.

.
Gender Minority Identity
LGBTQ-based School
Stress and Violence
Suicide Ideation
Suicide Attempt

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Chapter 5. (Study 3): A Qualitative Exploration of the Experiences of Transgender and
Gender Nonbinary Adolescents with Support and Stress in School

Study 3 Abstract
Background: Transgender and gender nonbinary (TGNB) youth and adolescents encounter
violence such as bullying in their schooling experience. Further, they have poorer perceptions of
their school climate in comparison with their cisgender peers. The present study explored how
transgender students and their parents describe experiences of stress and support in schooling.
Methods: Life history calendar interviews of 20 dyads (i.e., TGNB student and one parent) were
analyzed using a multi-stage standardized thematic analysis using the gender minority stress
theory as a sensitizing framework. Youth were recruited from a gender-affirming clinic and
family support group in the Los Angeles area and were eligible if TGNB, age 13-18 years old,
and having begun a gender affirmative health care procedure (hormone blockers or gender
affirmative hormone therapy) within the previous six months of eligibility screening.
Results: Three main themes emerged from analysis, 1) Support, 2) Gender Minority Stress, and
3) Mental Health. Study respondents described experiences of support in schools from peers,
teachers, and administration. Participants also reported gender minority stress in the form of
distal (i.e., targeted violence and discrimination) and proximal (i.e., intrapersonal) stress within
their schooling and from peers, teachers and administrators. Youth and families discussed and
exhibited coping with these gender minority stressors. Finally, negative mental health and
neurodivergence (e.g., such as autism spectrum condition) was common among students.
Conclusions & Implications: Schools can be sites of stress and support. School social workers
must be cognizant of the experiences and needs of TGNB students and intervene to support

81
them. In our data, supportive teachers, peers and administrators were described as positive
factors in the lives of TGNB students as well as by their parents. Adequate resources should be
channeled to develop a school social work workforce since school social workers are uniquely
positioned to support the needs of TGNB young people. School social workers can foster
supportive schools by developing TGNB affirmative-knowledge, skills and behaviors among
teachers, administrators and students. Further, school social workers can usefully identify and
empathetically support TGNB students, including those who are neurodivergent.

Keywords: Transgender, school climate, gender minority stress, qualitative research

82
A Qualitative Exploration of the Experiences of Transgender and Gender Nonbinary
Adolescents with Support and Stress in School
Background
Transgender and gender nonbinary (i.e., TGNB) students are those whose sex assigned to
them at birth does not match their gender identity (Hendricks & Testa, 2012; The GenIUSS
Group, 2014). Gender identity is a core aspect of one’s identity and is an internalized sense of
gender as a boy/man, girl/woman, a mixture of both or a different identity. Recent U.S. national
prevalence estimates of TGNB gender identity range between just under 1% up to 3.4% of the
national population (Herman et al., 2017). As for young people, 0.7%, or at least one hundred
and fifty thousand youth aged 13-17 in the U.S. identify as TGNB (Herman et al., 2017).
However, gender identity measurement limitations suggest that the true prevalence of TGNB
young people may be higher than existing estimates (Meerwijk & Sevelius, 2017).
Violence, Discrimination and Mental Health
TGNB young people experience high rates of violence which are associated with
negative health and wellbeing. Data from U.S. crime reports statistics show that violence starts
early in the lives of TGNB people and includes physical, verbal and sexual forms of violence
(Meerwijk & Sevelius, 2017), and even homicide (Dinno, 2017). In one state-wide study in the
Eastern U.S., 40% of TGNB respondents reported ever having experienced gender identity-based
physical violence (Xavier et al., 2007). Further, TGNB young people report polyvictimization
(i.e., a combination of 15 or more experiences of crime, child maltreatment, peer and sibling
victimization, sexual victimization, and indirect and witnessed victimization) at a significantly
greater rate than cisgender youth with more than 65% of genderqueer youth assigned male at
birth being polyvictimized (Sterzing et al., 2019). Other research has corroborated that TGNB

83
people report more discrimination than cisgender sexual minorities (Su et al., 2016). For TGNB
adolescents, violence is associated with negative mental health outcomes. Among a sample of
San Francisco bay area transgender young women (n = 216), gender identity-based
discrimination was associated with PTSD, depression, and stress due to suicidal thinking (Wilson
et al., 2016).
Gender Minority Stress Theory
Interpersonal and structural violence and harassment such as sexual violence and
discriminatory policies [e.g., bans on bathroom use (Bender-Baird, 2016; Wernick et al., 2017)],
are thought to explain the population level etiology of negative mental health among TGNB
people (Chodzen et al., 2019; Hendricks & Testa, 2012; Testa et al., 2015). Gender minority
stress theory posits that social environmental circumstances that devalue gender minority
experiences lead to TGNB people being targeted for violence. Experiences of violence in the
social environment in turn lead to perceptions that one will continue to experience more violence
because of one’s identity. A consistent perceived threat of violence because of one’s authentic
identity fosters internalized self-hatred and feelings that one need hide who one is. Thus, chronic
stress from social (i.e., targeted violence or distal stress) and intrapersonal (i.e., proximal stress)
factors burdens individuals’ ability to cope and can lead to negative mental health outcomes.
This gender minority stress pathway from social environmental circumstances to negative health
outcomes provides a helpful heuristic for school social work researchers to approach intervention
for TGNB health and wellbeing. Research that uses this stress pathway framework
contextualized to specific social institutions (e.g., prisons, schools, healthcare clinics) is needed
(White Hughto et al., 2015), especially to assist in the identification and explanation of context

84
specific supportive factors that may moderate and reduce the negative impacts of stress on
mental health (Hatzenbuehler, 2009).
Gender Minority Stress and Qualitative School-based Research
Though research has examined LGBTQ students’ school-based experiences as a whole,
only one study has qualitatively examined TGNB young people’s experiences of stress and
violence in school (McGuire et al., 2010). This study, conducted over one decade ago, used four
focus groups and reported that TGNB young people discuss pervasive violence in their schooling
and that this violence is associated with negative mental health (McGuire et al., 2010). Further, it
has been highlighted in quantitative research that lack of supportive parents is related to negative
mental health among TGNB young people (Simons et al., 2013; Wilson et al., 2016). However,
the role of parents in TGNB students’ school-based experiences has not been as well explored. In
all, research examining salient factors for TGNB student wellbeing is needed for school social
workers to address TGNB students’ needs using evidence-based practices (Day & Russell, 2018;
Gower et al., 2018; Hatchel & Marx, 2018; Marx & Kettrey, 2016; Proctor et al., 2016). Inquiry
into the school-based experiences of TGNB young people using the gender minority stress
framework can help school social workers to understand how families experience the salient
factors [i.e., gender minority stress (distal and proximal) and support] related to TGNB mental
health and wellbeing. A more thorough understanding of TGNB students’ and parents’
experiences with school will help social workers to align with an evidence-based school social
work practice, and to inform potentially supportive policy.

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TGNB Students at School
School Violence as Gender Minority Stress
Schools are particularly important environments that influence trajectories of health for
youth and where encounters with school violence are frequent and associated with negative
health and wellbeing for all students including TGNB students (Astor & Benbenishty, 2018;
Johns et al., 2019; Lester et al., 2017; Thapa et al., 2013). For example, bullying and harassment
are common in schools across the United States, with the National Center for Education
Statistics showing that 21% of students report last-year bullying (Lessne & Cidade, 2015).
TGNB students experience heightened rates of school violence compared with cisgender student
peers, including higher rates of last year bullying (Johns et al., 2019). School-based pilot data
from ten U.S. states and nine urban school districts (n = 131,901) showed that more than one
third of TGNB students report being bullied at school while nearly 30% report cyberbullying
from peers (Johns et al., 2019). Additionally, nearly 27% of TGNB students report feeling unsafe
at or on the way to school, and about 24% report threats or injuries with a weapon at school
(Johns et al., 2019).
The Relationship of School-based Gender Minority Stress with Mental Health
School violence is associated with TGNB students’ negative academic outcomes as well
as poor mental health including, depression, anxiety, and suicidal ideation and attempt (Kosciw
et al., 2018; Pedro & Esqueda, 2017; Toomey et al., 2012; Wernick et al., 2014). Prevalence of
suicide attempt among TGNB students is high, with 35% of TGNB youth reporting a lifetime
suicide attempt (Johns et al., 2019). Certain subgroups of TGNB students have even higher
prevalence of lifetime suicide attempt with 50.8% of transmasculine young people in one study
(n = 120,617) reporting lifetime attempt (Toomey et al., 2018). Gender minority stress in school

86
settings is likely important in explaining these mental health outcomes. One study (n = 245)
showed that sexual and gender minority youth who reported a high level of LGBTQ-targeted
harassment had nearly 6 times higher odds of suicide attempt compared with those who did not
experience high LGBTQ-targeted harassment (Russell et al., 2011). Further, qualitative pilot
research with a small group of TGNB young adults (n = 13) showed that though they wished for
schools to be supportive places, barriers such as violence often prevented positive mental health
(Singh, 2013).
Social Support: A Moderator of the Relationship Between Gender Minority Stress and Mental
Health
Supportive peers, teachers and administrators as well as LGBTQ-supportive policies and
practices such as the presence of Gender-Sexuality Alliances (i.e., GSAs, which are LGBTQ
student coalitions at school) relate to lower school violence experience and better mental health
for TGNB students (Day et al., 2019; Dessel et al., 2017; Swanson & Gettinger, 2016; Wernick
et al., 2014). Historically, GSAs began as social support groups focused on sexual minority
youths but have more recently been inclusive of TGNB students. Data has shown that the
presence of a GSA on campus is associated with reduced likelihood that LGBTQ youth as a
whole will report LGBTQ-targeted bullying from peers, while the presence of LGBTQ-
affirmative policies is associated with increased reports of support from teachers (Day et al.,
2019). The presence of just a few supportive teachers and/or peers on a campus is important.
When peers and teachers witness others on campus intervene in anti-TGNB harassment and
bullying, they are more likely to also intervene in such bullying (Wernick et al., 2014; Zotti et
al., 2019). In qualitative research LGBTQ youth identified GSAs as fostering a sense of
belongingness at school, perceptions of safety and connections to resources like supportive peers

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and adults (Porta et al., 2017). The development of social support and positive school climates
for TGNB students may be an important and effective intervention point for school social
workers to address the violence and negative mental health of TGNB students, especially given
that teachers themselves have been documented to perpetrate targeted harassment toward
LGBTQ students (Smith & Payne, 2016; Swanson & Gettinger, 2016). Currently, most research
in this area in schools has looked at the experiences of sexual and gender minority students as a
whole, and more research is needed on how TGNB students specifically experience stress and
support in school (Day et al., 2019).
Research Questions
The present study uses the gender minority stress theory as a sensitizing conceptual
framework to explore experiences of schooling among TGNB students and their parent
caregivers with the aim of uncovering relevant themes of stress and support for TGNB students
and their parents. We developed the following two research questions:
1. How do TGNB students and their parent caregivers describe support in their schooling
experiences?
2. How do TGNB students and their parent caregivers describe stress in their schooling
experiences?
Methods
Research Team.
The social position of researchers influences the research process and interpretation of
results given their unique social standing within social hierarchies relative to research
participants (Anderson-Nathe et al., 2013). The analytic and writing research team consisted of
three social work doctoral level students (two doctoral candidates, and one doctoral student), as

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well as two professors (one at the assistant level in Public Health, and another at the associate
level in Social Work), all of whom are white. The gender identities of the analytic and writing
team included cisgender women and men and one gender nonbinary person. As for sexual
identities, the analytic and writing team represented a number of sexual minority identities (e.g.,
gay and queer). The interview team consisted of the two aforementioned doctoral candidates
each a trained social worker with an MSW degree, and two additional social workers with MSW
degrees. The lead interviewer was a white cisgender woman. Other interviewers were one white
cisgender queer man (the lead author on the present study), one white transmasculine person, and
one black transmasculine person.
Study Design
The guiding framework of the present study is the gender minority stress theory and its
associated model (for comprehensive model overvivew see: Testa et al., 2015, 2017). This body
of theoretical work posits that social environmental stress targeted at minority groups impacts
their self-evaluations which foster psychological expectations of rejection and violence. The
chronic burden of distal and proximal stress is thought to deplete TGNB people’s coping and
resilience, and to lead to the observed rates of elevated negative behavioral health. This model
was used to guide the development of study interview materials for use with TGNB youth and
their parents, which included questions to assess for support and gender minority stress related to
different domains of life, including within schooling. The study used a multi-stage standardized
thematic analysis (Braune & Clarke, 2006) that used the gender minority stress model and its
associated components, along with extant literature on the school-based experiences of TGNB
young people to develop an initial codebook that was then refined by coders through co-coding,
finalized through a process of consensual validation, and used to code all data. Thematic results

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were then used as a framework for presenting the school-based experiences of TGNB
adolescents, the importance of the gender minority stress model for understanding the behavioral
health of TGNB adolescents, and for organizing the implication of findings for social work
practice, policy and future research directions.
Procedures
This study draws on interviews of 20 dyads of TGNB adolescents and one of their parent
caregivers (i.e., 20 families). Families were enrolled using purposive sampling drawing
respondents from a TGNB adolescent healthcare provider in the Los Angeles area and an
established TGNB family support group. Families were informed of the study through flyers and
word-of-mouth. Interested families first conducted an eligibility screener by first calling or
emailing the PI who then conducted a short screener for eligibility and provided information on
study purpose, timeframe and procedures. Eligibility criteria included TGNB gender identity, age
13-18 years old, and having begun a gender affirming medical procedure (i.e., hormone blockers
or gender affirming hormone therapy) within the previous six months of eligibility screening.
Eligible and interested families then sat for two separate but concurrent interviews in a private
place of their choosing, often the family’s home. Separate but concurrent interviews allowed
respondents to share their experience without influence from their family member. Before
interview, informed consent was obtained from parent caregivers and assent was obtained from
adolescents, then once again consent and assent were obtained individually in interview rooms to
offer participants the opportunity to agree to participate without the presence of their family
member. Each interview lasted about one and a half hours and was audio recorded with
permission. Participants were incentivized with $30 in cash per participant, or $60 per family
dyad. Full board IRB approval was received for the present study.

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Interviews followed a semi-structured protocol utilizing a life history calendar approach
based on the gender minority stress model. The life history calendar allows for a chronological
approach to qualitative data collection that allows for increased recall of historical events over
the life of adolescents and adults (Fisher, 2012). Life history interviews covered many pertinent
domains of life, including stressful and supportive experiences related to schooling (For more on
life history calendars, see: Freedman et al., 1988). Within the realm of school, open-ended
questions were asked about teacher, peer and administration experiences of support and/or
rejection. In the order that interviews were conducted families were anonymized by researchers
with an ‘A’ for adolescent or a ‘P’ for parent and a number beginning with 101 (e.g., A101,
P101, A102, P102 and so on to A120 and P120).
Analysis
Upon completion of interviews, audio recordings were transcribed verbatim and stored in
the qualitative research software program ATLAS.ti version 8.4.4. Multi-staged standardized
thematic analysis was used to identify central themes related to the stress and resilience of
TGNB students’ schooling (Boyatzis, 1998; Braun & Clarke, 2006). To start, the most basic
semantic elements related to schooling and gender minority stress were used to create an initial
codebook for open coding. These codes where grouped into 14 conceptual bins (e.g., teachers,
administration, role of peers, gender minority stress) and were used for a period of open coding.
During this time the two lead authors met weekly to discuss each coded dyad and refined and
organized the codebook given the experiences contained in the data. After a period in the co-
coding process where no new codes were developed (i.e., saturation) and a high level of
consistency was achieved between coders, a period of independent focused coding was entered
where all transcripts were coded with the finalized codebook. Through this period, coders

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continued to meet weekly to discuss experiences encountered in each transcript and potential
emerging themes and subthemes. Throughout the process of coding, authors maintained a journal
of memos to assist in the development of themes. Then, upon coding the first sixteen transcripts,
the lead coders began to organize data into overarching conceptual themes and related subthemes
arrived at through the use of the conceptual framework, what was present in the study data, and
interpretation. A high degree of consistency and reliability between coders was achieved through
a process of consensual validation whereby coders maintained notes on their process, and met
weekly to discuss issues during the periods of open and focused coding of all transcripts.
Results
The sample was comprised of twelve transmasculine adolescents and eight transfeminine
adolescents. Of the caregivers in the study sixteen identified themselves as a mother, and four as
a father. All caregivers (i.e., mothers and fathers) in this study were cisgender. The socio-
demographic characteristics of interviewed families are summarized in Table 1. Participants’
responses to semi-structured life history calendar interviews were broadly organized into the
following three overarching themes: 1) Support, 2) Gender Minority Stress, and 3) Mental
Health. The results of the three main themes are presented below along with structured sub-
themes for each.
Theme 1: Support
Theme 1.1: Teachers, Administrators, and School Support Professionals
Youth and their parents spoke about teachers, administrators, and school support
professionals (e.g., nurses and school psychologists, counselors and social workers) as sources of
support and affirmation. Support from these actors were often described in relation to facilitating
needed mental health support and improving mental health. Adolescents often described

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individual teachers as impactful, influential and positive. For example, one transgender boy
(A109) shared that their teacher facilitated access to needed mental health services:
I have like a really good relationship with one of the teachers…I saw him like a fatherly
figure, so I told him at the end of the year, when he left, he told me like, you know, you
are one of the kids that I like, that I’m sad to leave and I was just like, “No, stop, don’t
tell me this.” But um, he like, I ended up opening up to him [on social media], like it had
to be 1:00 am in the morning, it was really late…I was like, oh, like, I just want to run
away and my dysphoria is really bad and I was like “Dang, I just want to kill myself”
and I just say how I get urges to jump in front of traffic…He then told like, one of the
counselors at [my high school] and then that sent like County people over here…It was
positive.

Parents also identified teachers as important figures at school. One teacher assessed the needs of
their TGNB student and included TGNB people in their classroom curriculum. One parent of a
transgender male (P104) shared about their child:
He had an English teacher who did the sex education…she would cover sexual identity
and gender identity…she had the project about…writing about your name. And I guess
for that project…he was the only one who wrote about how much he hated his name…in
reading that, the English teacher kind of had a light bulb…[then she started assessing if
he was TGNB] and was trying to help him.

Teachers along with school administrators (e.g., principals) were often described by
TGNB students, and more often by parents, as important confidants at school who they could
communicate with for support and for problem-solving around gender-identity related barriers
including harassment and accessibility needs (e.g., bathroom use). For example, the parent of a
transgender boy (P116) consulted with their child’s middle school principal over the phone
anonymously on an ongoing and frequent basis about how to ensure their child was supported at
school. At the time, their child did not wish to disclose even to the principal, and the principal
understood the mother’s need to communicate with them anonymously. When this family was
ready to disclose, the mother shared of the experience:
[My husband and I] met with all the teachers, we came out…I told [the principal], [my
child’s gender therapist] came, we had a meeting with all the teachers and I, you know, it

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made me very emotional when they all showed up. Because all the teachers who were on
campus that day, showed up in that room with us and it was just pretty mind-blowing.
Even his one teacher that came over from the high school, he stayed and was there for
the meeting. And they were just so loving...It’s still so touching just like how open
everybody was.

School mental health professionals such as school social workers were also mentioned by
youth as facilitating their gender identity awareness and coming out processes. These school-
based professionals allowed adolescents to question and explore their gender identities and
assisted coping with distal stress. One gender nonbinary youth (A110) shared that their school
therapist facilitated their desire to come out to their parents and helped them cope with fear of
rejection:
One day I came to the therapy office, and just started crying and I was like, “I need to
tell my mom, but I am afraid to tell her by myself, can you call her?” And she did and
she’s like, “You have to tell her. I’ll call her, but you have to tell her.” So, I calmed down
and told my mom and…I could hear in her voice on the phone, she was like “I love you
no matter what.”

Further, school support professionals like school counselors were described as particularly
helpful when providing support empathically not just for gender-identity, but other issues, such
as those related to mental health. For example, the parent of one gender nonbinary youth (P105)
shared that their youths high school counselor was “amazing” because they shared that their own
father was TGNB, that they understood the family’s needs, and would ensure that their child’s
pronouns would be respected at school.
Theme 1.2: Peers
Peers were described as essential sources of social support and coping with gender
minority stress in our study. Student peers were often described by youth as helping them
through their gender identity awareness processes, including coming out. Adolescents frequently

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identified peer support in their school places. There were many examples of peer support in our
data. One transgender male in our study (A104) shared of their peers:
I never actually [disclosed]. It was my friend, my friend made like a wild guess…He said,
“Oh sometimes we have to save up money to save up for a Go Fund Me to fund like your
transition.” And I was like, wait what the hell?...Like I was not expecting that. And now
he is like “Oh god like that was such a crazy thing to ask” and I am like, well, I did [end
up transitioning].

This youth’s parent (P104) shared that it was their child’s close friend that commented about
funding their transition, and that this was helpful for them to begin disclosing to other peers. This
parent shared, “[His peers] were really supportive and some of them took like the role of
watching [him] and [were] like “OK I am going to make sure nobody picks on this kid.” Peers
provided support to youth around their gender identity, especially in regard to naming and
affirming participating youths’ minority gender expressions by using their names and pronouns.
The parent of a gender nonbinary child (P105) shared:
We [i.e., parents] didn’t know anything about [child’s chosen name], this name change.
And then we suddenly found out that he was being referred to he/him and [child’s chosen
name] at school for two or three weeks before we knew…by kids.

For this adolescent (A105) it was peer support received at school that allowed for exploration of
gender identity, support that was not available at the time in the context of the family.
In middle school, I started going to school as my dead name and female pronouns. But
when I came out to all of my friends, um and said that I feel more male than anything,
they completely understood. And I thought it would just be my group of friends but
somehow my entire class and then all the teachers and then all of a sudden everyone in
the school understood and were calling me [preferred name] and using male
pronouns…So, somehow it spread from my friends to the entire school and I was so
happy about that because everywhere I went it was just male pronouns and [preferred
name] and um my mom put me down in the high school I am going to as my dead name
and female pronouns because that was before I came out to her.

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Theme 1.3: School Structures
Adolescents in our study identified practices and structures (i.e., policies and practices) at
their elementary, middle and high schools that supported their minority gender identities and
provided them opportunities to be affirmed in the ways and on the timeline that youth and their
families desired. For example, the parent of a transgender girl (P102) stated that their middle
school was supportive given an abundance of resources including counselors and staff trained for
LGBTQ-affirmative practices, a GSA, and bathroom and locker room accommodations. This
parent shared that their child’s school was proactive in communicating the availability of TGNB
resources before school enrollment. Unsurprisingly, this parent found that starting at this middle
school coincided with a dramatic positive change in the youth’s mental wellbeing. The parent of
this transgender girl (P102) shared:
I would say this school year has been the one where we are both, my husband and I are
like, Oh my god. This is what like parents get to experience? Like they get to send their
kid to school and like the kid smiles? Like, we never experienced that.

Administrators with supportive structures asked families about their needs and offered options
that aligned with the family’s desires for support and gender identity affirmation. For example,
when one transgender male (A104) was ready to disclose their gender identity to peers, they
were given a variety of options for doing so by their administration and chose one that was
aligned with what felt comfortable for them, in their case, having their identity disclosed to the
middle school by an administrator in a “mass-coming out session.” Additionally, adolescents and
their parents frequently mentioned GSAs as supportive by families. The parent of a transgender
girl (P102) named GSAs as a comforting resource on their youth’s middle school campus. When
asked about the impactful resources on their campus one transgender boy (A109) responded
stating that it was the GSA, for which they served as Vice President.

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Theme 2: Gender Minority Stress
Study respondents shared many experiences of distal and proximal gender minority
stressors in their schools. The parent of a transgender girl (P102) said of their youth’s experience
with elementary school, “Every single day she hated going to that school.” Youth and their
families also told us about the manifold ways in which they coped with stressors at school.
Theme 2.1: Distal Stress
Theme 2.1.1: Harassment and Bullying. Both verbal and physical harassment and
bullying were pervasive and explicitly described by almost every single respondent in our study.
The parent of a transgender girl (P107) shared the following experience of her children:
They were on the school bus one time…[and my cisgender daughter] gives me a slip that
the bus driver gave to her. And I’m like “What happened”? And she’s like, “That boy
jumped on [TGNB daughter and]...started hitting [her].” So, my daughter jumped on top
of him and started hitting him. And she got suspended off the bus for a couple days…And
I was just livid. I was so mad. And I’m like, “This boy is hitting you? That hurts me.” You
know that’s my child and to know that [she] is going to school every day and getting
[harassed]. It drove me crazy. So, I went to school the next day and was like “You guys
are letting my daughter on the dam bus. If you are going to kick anybody off the bus, it’s
going to be that boy that picks on [TGNB daughter].” I’ve been to school twice already
because of the same kid that keeps picking on [my TGNB daughter] and my daughter is
going to get off the bus? I don’t fucking think so.

Respondents in our study shared that perpetrators of harassment and bullying were not only
student peers, but teachers who, in some cases, knowingly refused to respect TGNB student
gender pronouns, or who allowed harassment to continue without intervening. One transgender
male (A113) reported:
[Teachers] weren’t really like going to step in when there was a bully situation, so it was
just, you know, whatever…I wasn’t very like physically hurt but I wish teachers would
have stepped in with like, you know, verbal stuff [to stop the harassment].

Parents similarly shared their perceptions of teachers as perpetrators of gender-identity based
discrimination. The parents of one transgender girl (P102) shared:

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The teacher pointed out, “We provide blankets for the children because it gets cold in the
room, but your child doesn’t use the blankets like other children.” And we were like
what? And she was like “Your child, kids are making fun of him because your child
would make it like a skirt um and you know it’s a little disturbing that you know your
child does that.” But I would never say to my child don’t do that.

Theme 2.1.2: Problems with School Structures. Youth and their parents identified
many experiences that were stressful due to structures at school, or lack thereof, that were
discriminatory based upon student gender identity. The parents of one transgender girl (A102)
shared of their child’s coming out experience at their community elementary school:
I called the principal and said, “[My daughter] wants to come to school tomorrow and
tell everyone that she is [transgender]”…and the principal said, “Wait a second…I gotta
make some phone calls so, can you keep her home tomorrow?”…then it got a little bit
hard because the principal had to call the lawyer and Superintendent, and so I was on
speaker phone a lot with all these people. And they were really scared…the lawyer
decided, “Lets draft up a letter to inform all the parents. And we are going to send a
letter so let’s [have your child] stay out of school.” And the letter [said]…there is a child
in school transitioning from male to female so please use female, she/her pronouns and
it’s called being transgender, here is some websites, here is some information um…I
hated it… And the day [she was permitted back at school, more than a week later]…there
was a news van there and…because the entire school got the letter…kids were like, “Yea,
oh my god that’s the one, that’s the one [to my daughter].”

This family’s elementary school lacked any affirmative policy or structure to support TGNB
students with their gender identity disclosure and transition at school, which were reported by the
family to be a major stressor. For lack of a policy to protect transgender youth privacy and ease
of school-based transition, the youth’s opportunity to self-disclose and maintain privacy was
removed, placing them at greater potential risk of bullying and mistreatment.
TGNB students also reported that gender-segregated school structures caused them stress.
Though literature has documented a negative impact on gender equality from gender segregation
in schools (Thorne, 1993), gender segregated activities were commonly reported in our study.
One transgender boy (A112) shared that they could not receive sexual health education in school
because students were segregated by their birth assigned sex. This adolescent was not

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comfortable attending class with girls but was not allowed to attend with the boys either. Instead,
the parents of this transgender boy (P112) were charged with seeking out their own resources for
sexual health, which they found through a local church group. While this family was able to find
a resource for sexual health, other youth lamented not being able to find any sexual health
information. For example, one transgender male (A108) explained that they did not get LGBTQ
inclusive sexual health curriculum at school and only felt comfortable asking related questions of
online friends. Additionally, youth shared that gender segregation in bathrooms and locker rooms
was a common stressor. Many youth and parents reported that their children stopped using the
restroom on campus altogether and found ways to excuse themselves from physical education
(PE) so that they would not have to deal with the distress of body dysphoria around peers in
locker rooms. The parent of a transgender boy (P116) shared:
[My son] missed a lot of PE. He like, he had some injury, I think he just did it on purpose,
I really think he, I was at the orthopedic specialist constantly. Um, [he] like, twisted his
ankle or something so he couldn’t run.

While this youth went to the greater extent of self-harm to avoid gender-segregated locker
rooms, other parents described tactics to avoid PE and gender segregated locker rooms, such as
getting medical exemptions from physicians. Some youth wished that their schools were more
prepared to support them given structural deficiencies in regard to TGNB student support that
they encountered, for example one transgender girl (A118) hoped “There could have been
education about transgender kids in my school [because] no one knew it was okay to be
transgender.”
Theme 2.1.3: Political & Governmental stressors. Youth discussed recent political
changes in the U.S. as pervasive sources of distal stress. Youth were aware of federal and state

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policies that limited their safety and ability to be affirmed at school. For example, when asked
about their future goals, one transgender young woman (A111) shared about their college plans:
I specifically did not even look into any colleges or any state that does not have laws
protecting me. You know, if it’s not illegal to discriminate against trans people on the
base, in housing or jobs, I mean no, I am not going, I’m not going to that state.

Theme 2.2: Proximal Stress
Parents and youth in our study described encounters with consistent and sustained
proximal stress in their schooling experience. Notably, youth consistently reported 1)
concealment of their TGNB identities and 2) social isolation due to expectations that they would
be rejected. A need to conceal one’s TGNB experience was of the utmost importance to many
adolescents interviewed in our study, especially though not exclusively for transmasculine young
people. This need created stress across school contexts including with bathroom use, in the
classroom and with peers. For example, one transgender boy (A109) explained that they stopped
going to the bathroom at school to avoid the attention of others and to assist with identity
concealment:
There were one-stall gender neutral bathrooms and that’s what like, what I’m most
comfortable with. And those were only for teachers unless you were trans and everything.
But the thing is…people were noticing, and it would draw attention to me. And that
would also get me really worked up and anxious. Um, and I remember, like after I got
hospitalized [following a suicide attempt], like, I had stopped using the restrooms
because I just was like, I just got so scared and people noticing and ugh.

Further, one transgender girl (A118) expressed a need to conceal their transgender identity in
order to avoid stress, “I don’t want to do everything a transgender kid would do, I want to do
what a normal kid would do without the stress of a transgender person.”
Youth in our study frequently reported being socially isolated due to their expectations
that they would be rejected. For example, one transgender girl (A114) shared, “I didn’t like
being around the other kids… [I thought,] are they going to be mean to me?” Parents were

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aware and concerned about the social isolation of their children. The father of one transgender
young man (A115) explained:
I wish [he] had more friends because, I think it was more on the lines of, he considers
[mom] and I to be his best friends which…I want my kid to be out there with his peers,
not with me. [Being] transgender…is a big component of that [i.e., of social isolation].
Theme 2.3: Coping
Theme 2.3.1: Clubs (e.g., GSAs), sports, and extracurricular activities. Youth and
parents in our study described clubs such as GSAs, sports, and other extracurricular activities as
important sources of affirmation and coping with distal and proximal stressors. One transgender
male (A104) stated, “Ninth grade…I guess what kind of changed is…I found my passion, like
debate as a formal support type activity.” They go on to explain that the debate club gave them a
sense of purpose and worth that was related to their improving mental health. One transgender
girl (A107) reported similar benefits from cheerleading where they found both affirmation and
increasing feelings of self-worth. Their parent (P107) recognized this and shared upon letting
their transgender daughter switch from football to cheerleading: “[She] joined the [cheer] team.
And, it was just like a completely different person. Like, [she] became someone else. And I felt so
good”
Theme 2.3.2: Self-efficacy. Study respondents shared many ways in which they engaged
in advocacy to support their own needs to cope with gender minority stress at school. Most all
parents were in frequent contact with their children’s schools to ensure support was provided and
to address gender minority stressors. Parents reported making difficult decisions to advocate for
their children’s needs when solutions could not be found at school. For example, The parent of
one transgender girl (A107), in response to a targeted assault of her daughter on the school bus,
and multiple conversations with school officials that did not lead to a resolution stated, “I’m not
putting up with it, I can’t deal with it… they are going to private school.” Adolescents engaged

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in advocacy to have their needs met at school as well. One transgender male (A106),
understanding the positive role that GSAs have on TGNB youth started one on their campus: “I
am starting a [GSA]…. I am President…this other teacher is running it and she is helping
me…and it’s going to be so fun.” As a further example, one transgender boy (A109) advocated
for access for all students to a gender-neutral bathroom:
My sophomore year, we tried to get a gender-neutral bathroom for trans kids…I was
actually the one who came up with it and was like ‘let’s do this.’ But then, something with
the district and also the fact that kids will try to abuse it [so it was not permitted…come-
on!... It was a supportive experience because it was like telling them like, hey [it’s my
right to have this].

Furthermore, the father of one transgender girl (P118) recognizing a lack of education about
human gender and sexuality at his daughter’s school shared resources with his daughter’s
principal on how to receive training. The resources were ignored, and ultimately the family
decided to move their daughter to a private school they felt would be more affirmative.
Theme 2.3.3: Pride and Connection. Some youth in our study expressed the importance
of having pride in oneself, and with the LGBTQ community. These sentiments assisted youth to
cope with gender minority stress. This was demonstrated by youth in their desire to participate in
GSAs. Also, some youth, particularly older youth though not exclusively, expressed pride in
their TGNB identities. One transgender young woman (A103) provided a poignant example of
this pride:
It was terrifying at first…[but] realizing that I was happy now and that I was really living
was more this decision I had to make for myself…I decided I can either transition back
and be safe…and die of stress stomach aches or I can transition and get killed by some
transphobe but at least one way I would be happy. So, I just started getting more and
more over my fear…and became increasingly um proud and happy with my identity.

A young transgender girl (A118) shared in their interview:
I want to be who I want to be without a droplet of fear – that fear builds up but you can
transfer it into strength, and in that way [transgender kids] become stronger than a lot of

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other people. And we get scars, and our scars are what make us the most beautiful and
important and unique people.
Theme 3: Mental Health
Reports of mental illness including anxiety, depression and suicidal thinking that
interfered with school were commonly reported by almost every adolescent in the study. For
example, one transgender male (A104) shared that they had thoughts of killing themselves in the
ninth grade. They shared this with friends:
I had this one friend who decided to take me to the school therapist because I wasn’t
going to my classes that day because I was so done and tired. So, she pulled me to the
school therapist and then like the school therapist assessed me and determined that I
should probably go to the hospital.

Often, youth reported that anxiety and depression dissipated in their lives as they began to
transition into their authentic gender identities and expressions at school. For example, one
transgender girl (A102) shared, “I would have anxiety attacks every single day…it didn’t go
away until um, I came out at school in third grade.”
Neurodivergence in the Sample
Neurodivergence is a term emerging from disabled activism and disability studies and is
used to de-pathologize and reduce stigma associated with atypical neurological states including
diagnosed or undiagnosed autism spectrum condition (ASC), attention deficit hyperactivity
disorder (ADHD) sensory processing issues and oppositional defiance (Mackenzie & Watts,
2011). Though not an explicit theme, it is important to note that over half (n = 12) of the
participating families (i.e., either adolescent, parent or both) in our study discussed experiences
with neurodivergence (e.g., eight discussed ASC, seven discussed ADHD, and four discussed
both ASC and ADHD). The experiences of neurodivergent TGNB youth and their parents in this
study indicate that they may face additional specific challenges in schools, including difficulties
making sense of their identities and needs in school, social isolation and challenges building and

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maintaining friendships and removal or transfer from the school context altogether due to their
complex needs. Some parents shared that TGNB identity and neurodivergence were inseparable,
contemporaneous and stressful aspects of their child’s experience. The parent of one gender
nonbinary youth (P105) shared how this impacted their learning:
[He] has a focus problem, always had that. Focus and concentration. Whether that has
anything to do with all this, I don’t know. Maybe not in the early days but obviously now.
If he’s too busy thinking about “I’m feeling uncomfortable” or “I’m feeling dysphoric”,
you know, he can’t focus and that’s, that’s hard.

Respondents also reported that parents, teachers, and staff often approached neuro-divergent
children’s experiences and needs narrowly without considering the totality of the children’s
experience as both TGNB and neurodivergent. One gender nonbinary young person (A110)
shared that fears around the bathroom due to gender dysphoria were unaddressed due to
conflations with ASC:
I’m on the spectrum, I was a lot lower functioning [and] got bullied a lot for it. [I] didn’t
know how to act. I was always really angry…I hated using the restroom. Like, at home I
could use the restroom just fine. But like, in class, I would literally piss myself because I
didn’t want to go to the bathroom. [My teacher] thought it was related to me being on the
spectrum. She thought I just like couldn’t help it, or I was retarded or something. Like,
I’m not… I didn’t know [it was related to gender identity].

Additionally, TGNB neurodivergent youth were frequently schooled in nontraditional settings
(e.g., at home, or in therapeutic schools) because of their complex needs. The parent of the
gender nonbinary youth in the example above (P110) explained that exclusion from traditional
schooling was not a desired outcome for the family, but that they were left with no other options
given that their adolescent’s needs were not being met in a traditional school setting: “The school
district had recommended some residential schools, but we weren’t ready to send him away at
that point. We were like, ‘Whoa whoa, that’s like pretty traumatic, there’s gotta be something
else we can do.’”

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Discussion
The purpose of the present study was to examine TGNB students’ and their parent
caregivers’ experiences of gender minority stress and support in navigating schooling. We found
that adolescent participants reported many types of distal and proximal gender minority stressors
as they navigated schooling, experiences that were corroborated by and impacted their parent
caregivers. Parents and adolescents also shared experiences of social support in their schools
from peers, teachers, administrators and school support professionals such as school counselors.
Social support also came from structural factors such as LGBTQ-affirmative policies and
practices and LGBTQ student coalitions.
In line with existing empirical literature on TGNB students’ experiences with schooling,
reports of violence in the form of bullying and harassment based upon gender identity were
frequently reported by youth and parents (Day et al., 2019; Day & Russell, 2018; Johns et al.,
2019; Sterzing et al., 2019). Youth in our study consistently reported verbal, and to a lesser
degree physical violence in the school setting in the form of bullying by both peers and teachers.
Our study adds qualitative depth to existing literature and demonstrates the impact that this
violence has on TGNB students and their parents, who reported stress from their children’s
encounters with violence and discrimination at school and their need to engage in advocacy to
ensure their children’s needs were addressed. Further, families discussed the effect of distal
stressors in schools like the lack of TGNB affirmative policies and practices, gender segregation
of school activities, bathrooms, and locker rooms, and aforementioned targeted verbal and
physical harassment and assault. Each of these factors has been identified in research with
TGNB young people as correlates of poor mental health, poor academic performance, and low
levels of school belongingness (Bender-Baird, 2016; Day & Russell, 2018; Kosciw et al., 2018;

105
Matsuzaka, 2018). Our study is useful as it adds narrative example and poignance to how
affirmation at school across structures and by peers, teachers and administrators can result in
positive academic results and improving mental wellbeing.
Negative mental health, including depression, anxiety, suicide ideation and suicide
attempt were common experiences among interviewed families, which was not surprising given
the high rates of negative mental health recorded among TGNB youth in comparison to
cisgender peers (Connolly et al., 2016). Furthermore, reflective of recent findings (Lehmann &
Leavey, 2017; Mahfouda et al., 2019; Nabbijohn et al., 2019; Simons et al., 2013; Stagg &
Vincent, 2019), many TGNB youth in the sample were neurodivergent. An important finding
related to families’ discussions of mental health was that schools sometimes responded to TGNB
students who are neurodivergent or who live with negative mental health challenges by quickly
recommending home or other alternative forms of schooling. This sends a message that TGNB
youth who are neurodivergent or living with mental health challenges may not be able to be
schooled in traditional settings.
Despite prevalent gender identity-based harassment and violence in school, we found that
school can be an important context where TGNB students can explore their gender expression
and identity, especially in the presence of supportive peers, teachers, administrators, school
support professionals and other resources described by families in our study. This aligns with
recent reports by scholars that the school place can provide an opportunity for TGNB young
people to experience affirmation and for healthy development (Russell et al., 2016; Swanson &
Gettinger, 2016). For many students, school was a place where they could expand their gender
identity awareness, use their gender pronouns, be affirmatively identified by peers as their
authentic selves, and develop positive self-worth. School social workers and allied school

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professionals are obliged to ensure TGNB youth have the opportunity for affirmative, healthy
development in school (American Psychological Association, 2015; Hunter & Hickerson, 2003;
NASW, 2017).
Gender Minority Stress Theory
The gender minority stress theory and its associated framework (Hendricks & Testa,
2012; Testa et al., 2015) was a helpful tool to organize and understand the relationship between
gender minority stress, social support and mental health experiences shared in interviews. The
gender minority stress heuristic may prove helpful for school social workers to assist with the
identification of circumstances in schools that may negatively affect TGNB student’s self-
evaluations and behavioral health. This model suggests social workers can change unsupportive
circumstances in schools and enhance social support of TGNB students through direct practice,
policy change, and continued research that moves the field toward the development of evidence-
based practices and interventions.
Implications for Practice and Policy
Individual and Group Practice Implications
TGNB young people have a right to equitable schooling and healthy development and
social workers in schools must intervene to ensure these basic needs are provided for (Day &
Russell, 2018; NASW, 2017). Our findings corroborate existing research that social support is
important for TGNB young people to develop positive evaluations of themselves, cope with fears
of rejection and internalized self-hatred and to overcome mental health challenges such as
anxiety and depression (Simons et al., 2013; Swanson & Gettinger, 2016; Wilson et al., 2016).
As in our interview data and from existing recommendations, developing TGNB affirmative

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schools may serve to improve the mental health and overall wellbeing of TGNB students
(Kosciw et al., 2018).
Given a lack of consistent affirmation from all teachers, peers and administrators in our
data, school social workers can foster gender-affirmative knowledge attitudes and behaviors
among adults at school through training of teachers on human gender and sexuality. Research
has shown that even among teachers who report intervention in LGBTQ-targeted bullying is
important, they are nonetheless unlikely to intervene (Swanson & Gettinger, 2016). When having
received training, however, teachers have higher odds of intervening in LGBTQ-targeted
bullying than their colleagues who have not been trained (Swanson & Gettinger, 2016). Research
in Europe found that teachers who reported having had more exposure to LGBTQ people were
less likely to feel LGBTQ-targeted bullying was legitimate (Zotti et al., 2019). Training
furthermore should cover how teachers can affirm TGNB students at school. Youth in our study
shared that there was little to no content in their course curriculum that highlighted the
experiences of TGNB people (e.g., in sexual health education). Including the experiences of
TGNB people in course content, for example teaching LGBTQ social history in the U.S., has
been described as an important way to increase LGBTQ student’s positive perceptions of their
school place and belongingness in school (Kosciw et al., 2018; McGarry, 2013; Vecellio, 2012).
School social workers can also work with students individually and in groups to provide
psychoeducation on human gender diversity and sexuality to promote the health and wellbeing of
TGNB students. Emerging research has demonstrated that psychoeducation for all youth in
schools, including TGNB youth, on gender diversity and sexuality can affirm youth questioning
their identities and provide them the tools to build self-awareness in addition to reducing targeted
bullying of LGBTQ students across the school (Heck, 2015; Mims et al., 2016). School social

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workers can collaborate with students and teachers to develop LGBTQ student coalitions (i.e.
GSAs) that provide these types of psychoeducational interventions to students which can connect
them to peer and adult social support and teach skills to cope with gender minority stress (Heck,
2015; Seelman et al., 2015).
Finally, school social workers should not feel that they are alone in developing schools
that affirm and support TGNB students. Building community partnerships between human
service organizations to meet the needs of clients has been a historical professional role of social
workers (Wertheimer et al., 2004). School social workers can reach out to local, state and
national LGBTQ community human service organizations to access available resources
including for example trainers to deliver human gender and sexuality diversity training and
education (For organizations that provide trainings to teachers and school employees see:
Lambda Legal; n.d.). Social workers have also historically been involved in fostering civic
engagement amongst clients (Rome & Hoechstetter, 2010). Building civic engagement amongst
TGNB students may be indicated given our data. Youth in our study described experiences of
pride and coping through involvement with LGBTQ student coalitions. LGBTQ student
coalitions are an opportunity to educate youth about the social and political issues relevant to the
lives of TGNB young people, to promote advocacy around these issues in their lives and in
society, and to promote volunteer participation in community events (e.g., pride celebrations,
LGBTQ-focused political action).
Policy Implications
Social workers can advocate within their schools, districts, states and nationally to ensure
affirmative policy changes are made that support the needs and experiences of TGNB students.
Enumerated anti-LGBTQ bullying and harassment policies inform all at school that TGNB

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students must be respected and that their affirmation is legally defensible. Such policies are
associated with reduced bullying of LGBTQ students by peers, increases in teacher intervention
in homophobic bullying, and lower levels of LGBTQ student suicidality in comparison with
schools without such policies (Day et al., 2019; Russell et al., 2010, 2016; Seelman & Walker,
2018; Swanson & Gettinger, 2016). Further, school social workers can advance policies that
ensure the inclusion of content on LGBTQ people and their experiences and needs across school
curricula including through comprehensive sexual health education. California’s FAIR act and
the California Healthy Youth Act, which changed the state’s education code to ensure inclusion
of LGBTQ people’s experiences and needs in the social science and health curricula can be used
as examples to help guide policies and legislation (For information on policies and
implementation examples see: California Department of Education, 2019; Vecellio, 2012).
Additionally, ensuring funding to train educators on human gender and sexuality, and the
implementation of policies to protect, educate and affirm TGNB students are important given
teachers reports that they lack the skills to support LGBTQ students even when they wish to do
so (Smith & Payne, 2016; Swanson & Gettinger, 2016; Zotti et al., 2019). Furthermore, given
frequent reports of gender segregated spaces and activities in our study, trainings should inform
educators on the long-established harms of gender segregation at school on gender equality and
TGNB students (Matsuzaka, 2018; Thorne, 1993). While gender segregation may be necessary
in some spaces (e.g., locker rooms), accommodations to meet the needs of TGNB youth (e.g., a
private space to change) should be provided for through policy to those TGNB students who
need it, and considerations should be made to limit gender segregation at school as much as
possible from early on (Thorne, 1993). Given the positive role of GSAs in supporting students
and teachers to affirm LGBTQ students as a whole, policies that expand and build the capacity of

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GSAs are warranted policy interventions (Heck, 2015; Marx & Kettrey, 2016; Seelman et al.,
2015). Finally, given the stress described by participating families due to policies and
governmental administrations that target TGNB people in society, it is important that social
workers work to overturn standing discriminatory policy and advocate for TGNB-inclusive
policy (e.g., advocacy to allow TGNB military service, and to remove barriers to TGNB-
affirmative medical care).
Limitations & Future Directions
This qualitative study relied on a sample of purposively drawn TGNB adolescents and
their parent caregivers from the Southern California area, therefore the findings cannot be
generalized to all TGNB youth. This is especially so given that adolescents in the present study
came from families with access to general and TGNB-specific healthcare, and that the sample
was largely comprised of white families. Further, given that the rate of TGNB adolescents who
skip or drop out of school may be high (Johns et al., 2019), future research with TGNB young
people not engaged with schooling is an important next step to understand and intervene in those
factors that keep them from their schooling. Furthermore, our study was limited to adolescents
who started care within the last six months and had family support to receive that care. Youth
without supportive families who do not have access to healthcare may report very differently
about their school-based experiences. Research on the schooling experiences and needs of
TGNB adolescents who do not have supportive families is also needed. Such research will
further highlight the importance that social support plays in moderating the health outcomes of
TGNB students. Additionally, the research team was largely white and cisgender influencing our
interpretation of interviews. Also, research team demographics may have influenced the comfort
of research participants and results may have been different with more TGNB researchers and/or

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researchers of color. While most interviews took place in respondents’ homes, some study
participants opted to participate by meeting with researches in a university setting (i.e., at a
school of social work) which may have affected respondent comfort and may have skewed
results between those who participated at home and those who did not. Finally, only four
caregivers who identified as fathers participated in the study and more research is needed to
discern differences in stress and support in schooling of TGNB students between fathers and
mothers.
Future research is needed that examines the role of teachers, administrators and staff such
as school social workers on the experiences of TGNB students. Young people in our study
described the importance of supportive teachers and administrators in relation to their access to
needed services as well as academic and mental health outcomes and more work is needed to
fully illustrate these relationships. Recent research has shown that school-based student
outcomes are linked to teachers, administrators and staff as well as many other contextual factors
(e.g., school organization and mission) (Astor & Benbenishty, 2018; Capp et al., 2018; Moore et
al., 2020). The role of such factors as neighborhood characteristics, school resources, leadership,
mission and their relationship to TGNB students are needed. Furthermore, this research is needed
with attention to various geographic localities across the United States (e.g., non-metropolitan
and non-coastal regions) and with whole-school comparisons that can demonstrate the
differences between TGNB students in schools with affirmative practices and policies, and those
that lack them.
Finally, research to understand the experiences at the intersection of neurodivergence and
TGNB identity in the school-place are needed. The current study explored mental health
experiences when shared spontaneously by families but did not measure diagnoses clinically and

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relied on self-report. Results pertaining to this overlap should be interpreted cautiously. This
study does not establish evidence on the experience of neurodivergent TGNB young people and
results cannot be generalized. Literature indicates co-occurrence of ASC, sensory processing,
oppositional defiance disorders and attention deficit hyperactivity disorder (ADHD) in TGNB
samples (Mahfouda et al., 2019; Nabbijohn et al., 2019; Stagg & Vincent, 2019). However, there
are inconsistencies in the literature and recent systematic analysis has found that some studies
linking ASC and ADHD to TGNB identity have sampling biases and inconsistent use of
diagnostic tools for ASC, ADHD, and gender identity (Thrower et al., 2020). While evidence
appears to support a link between ASC and ADHD with gender dysphoria, symptoms overlap
between these diagnoses such that validated ASC and ADHD screenings specific to TGNB
populations are needed. In light of inconsistencies in the literature more research is needed to
understand and support TGNB youth in schools who may have a higher likelihood than
cisgender peers of being neurodivergent, and who may therefore face multiple stigmas and
identity development challenges at school.
Conclusion
Schools are important and foundational institutions in the United States that send
messages about what and how we want our society to be as a whole (Astor & Benbenishty,
2018). Our data suggest that TGNB adolescents report that they are not fully included in
schooling due to prevalent gender minority stressors from peers, teachers and administrators and
school structures that subject them and their families to stress, violence, and unaddressed needs.
However, there were many hopeful examples of social support of TGNB students and their
families in our data as well, which demonstrate the opportunity that school sites can provide for
TGNB youth healthy development. School social workers are well equipped to educate their

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colleagues and students on the experiences and needs of TGNB students and to intervene through
practice and policy change to uplift these minority young people.

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Table 5.1 Sociodemographic Composition of the Sample
Family
ID
Adolescent
Assigned
Sex at Birth
Adolescent
Age
Adolescent Gender Racial and/or Ethnic
Identity
Caregiver
Interviewed
101 Female 15 Transgender Male White Mother
102 Male 13 Transgender Girl Multiracial,
White and Latinx
Mother
103 Male 17 Transgender
Woman
White Mother
104 Female 15 Transgender Male White Mother
105 Female 13 Gender Nonbinary White Mother
106 Female 13 Transgender Male White Mother
107 Male 16 Transgender
Girl/Woman
Puerto Rican Mother
108 Female 13 Transgender Male White Mother
109 Female 16 Transgender Boy Multiracial,
Asian and White
Mother
110 Female 14 Gender Nonbinary Latinx Father
111 Male 17 Transgender
Woman
White Father
112 Female 13 Transgender Boy Multiracial,
White and Black
Mother
113 Female 15 Transgender Male White Mother
114 Male 14 Transgender Girl White Mother
115 Female 15 Transgender Man White Father
116 Female 14 Transgender Boy White Mother
117 Male 13 Girl Middle
Eastern/North
African
Mother
118 Male 12 Transgender Girl White Father
119 Male 14 Girl/Woman White Mother
120 Female 15 Girl/Woman Guy Multiracial, Middle
Eastern/North
African and White
Mother

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Chapter 6. Conclusion
This dissertation sought to expand knowledge on the school-based experiences of
transgender and gender nonbinary (TGNB) young people. Data have illustrated that TGNB
people experience violence and victimization in society throughout their lifetimes (Dinno, 2017;
Klemmer et al., 2018; Stotzer, 2008, 2009; Testa et al., 2012). Further, violence and
victimization based upon gender identity and expression has been shown to relate to poor mental
health outcomes including substance use, anxiety, depression, suicidal ideation and suicide
attempt (Bauer et al., 2015; Bazargan & Galvan, 2012; Klemmer et al., 2018; Testa et al., 2012).
However, most research with TGNB people has been on adults and the experiences of TGNB
young people have been less thoroughly examined (Tishelman et al., 2015; Wirtz et al., 2018).
Youth and adolescence are an important time of life that set trajectories of future health (Sawyer
et al., 2012). Having a thorough understanding of the experiences of TGNB young people is
particularly important to inform policy and clinical practice and to prevent adolescent and later
life mental illness (i.e., suicide ideation and attempt), thus this dissertation explored the
experiences of these young people.
Schools are particularly important sites that impact the health and wellbeing of all young
people who attend school including those with a TGNB identity (Astor & Benbenishty, 2018;
Marx & Kettrey, 2016). Recent research has suggested that TGNB young people may comprise
about 2% of the student population in the United States (Johns et al., 2019). Further, TGNB
students are more likely to report violence and bullying at school, and more likely to report
suicidal ideation and attempt than their cisgender peers (Johns et al., 2019). Nonetheless more
research is needed to broaden understandings of TGNB young people’s schooling, especially in
regard to encounters with school violence and to assess this groups’ perceptions of school

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climate (Day et al., 2018; McGuire et al., 2010). School climate is an important correlate of
school violence among general populations of youth and has been described as a fundamental
cause of students’ encounters with school violence and associated poor mental health like suicide
ideation (Astor & Benbenishty, 2018; Benbenishty et al., 2018). School climate measures include
students’ reports of safety, belongingness and support in their schooling, and research on these
experiences among TGNB young people is necessary yet currently limited (Day et al., 2018;
Thapa et al., 2013).
This dissertation relied on the gender minority stress framework of Testa and colleagues
(2015, 2017) to guide the conceptualization and exploration of students’ experiences at school.
Gender minority stress theory highlights the fundamental importance that social support and
affirming social environments can play in mitigating the negative relationship that violence and
victimization has with mental health outcomes. While the role of social support on protecting
from suicide ideation, suicide attempt and other negative mental health experiences has been
demonstrated, limited research has explored social support within the context of school and in
relation to the violence and mental health experiences of TGNB students specifically (Olsen et
al., 2014; Simons et al., 2013; Yeung & Leadbeater, 2010). Exploration of school violence,
school climate, and social support including that from teachers and parents has been strongly
indicated among TGNB students using representative and diverse (i.e., municipal, state, and
national) samples of students (De Pedro et al., 2018; Kosciw et al., 2018; McGuire et al., 2010;
Swanson & Gettinger, 2016).
Therefore, to expand the knowledge of allied education officials (i.e., teachers,
administrators, school staff, school support professionals and school social workers) on the needs
of TGNB students that they serve, this dissertation sought to fulfill six research aims and to

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answer four research questions through mixed-methods research (see chapter 1 p. 6 for
dissertation aims and questions). This chapter concludes the dissertation by reviewing the major
findings of these three analyses and integrates them with existing research on school violence,
school climate and mental health. Further, this chapter reviews important implications of this
dissertation for practice, policy and future research to develop safe and affirmative schools for
TGNB and all students.
Review of Major Findings and Integration with Existing Research
Using statewide data from a midland state of the U.S., this dissertation shows that TGNB
students report an elevated prevalence of school violence and have poorer perceptions of their
school climate compared with cisgender peers. Further, our results highlight the important role
that school climates characterized by limited social support of TGNB students have with
elevated risk for suicide ideation and attempt among TGNB young people. Finally, using in
depth life history calendars of TGNB students and their parent caregivers, we found that TGNB
students and their families discuss gender minority stress including targeted discrimination and
harassment due to being TGNB at school, in addition to having transformative experiences of
support at school, both of which are related to the mental health and wellness of these minority
youth. These interviews and empirical data illustrate the opportunity that schools have to provide
experiences of healthy development for TGNB young people. The following subsections will
review the independent findings of each paper in relation to existing research, and will then
provide a crosscutting discussion of key findings across the three studies that add depth to allied
education professionals understanding of TGNB students’ needs and experiences in the U.S.

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School Violence and Perceptions of School Climate Among TGNB Students: Paper 1
Paper 1 documented the prevalence of school violence and school climate perceptions of
TGNB adolescents in the state of Colorado using a combined dataset from the Colorado Healthy
Kids Survey administration years 2015 and 2017. Paper 1 also examined for significant
differences by gender identity controlling for sociodemographic characteristics (i.e., sex, age,
race or ethnicity, sexual orientation, and urbanicity). Our findings demonstrated that TGNB
students report more school violence than cisgender peers including proportionally greater
weapon carrying on campus, skipping school due to safety concerns, being threatened or injured
at school with a weapon, having been in a physical fight, and having been bullied. TGNB
students also reported participating in extracurricular activities, feeling safe at school, and feeling
that finishing school is important proportionally less than their cisgender student peers.
Regression analyses showed that TGNB students in Colorado had significantly greater odds of
reporting all forms of school violence compared with their cisgender peers. For example, TGNB
youth had 6 times higher odds of reporting skipping school due to safety concerns than cisgender
students in the state-wide sample (95% CI: 4.1, 8.7, p < .001). As for TGNB students’
perceptions of school climate, they have a significantly lower likelihood of reporting positive
school climate perceptions. For example, TGNB students in our sample had 78% lower odds of
reporting that they feel safe at school in comparison with their cisgender student peers (95% CI:
0.1, 0.4; p < .001).
The results of paper 1 corroborate previous research showing violence in the lives of
TGNB people is common. For example, a national study of New Zealand high school students in
2012 with a small number of TGNB respondents found that TGNB students had 4.5 times higher
odds of being bullied compared with cisgender students (95% CI: 2.4, 8.2; p < .001) (Clark et al.,

119
2014). Additionally, TGNB students in the study were less likely than cisgender peers to report
that they liked school (aOR: 0.3, 95% CI: 0.2, 0.4, p < .001). Our data are also similar to recent
estimates published in the United States where TGNB students reported significantly more
school violence like bullying, and significantly fewer reports that they feel safe at school
compared with cisgender peers (Johns et al., 2019). The results of paper 1 and existing studies on
school violence and school climate that include TGNB students’ experiences indicate that
intervention is needed to address school violence and poor perceptions of school climate among
TGNB students.
Social Support and Mental Health of TGNB Students: Paper 2
Paper 2 used data from 589 LGBTQ young people ages 12-24 years old who accessed an
emergency suicide crisis hotline to examine for relationships between LGBTQ-based school
stress and violence (indicated in part by lack of peer and teacher support), gender identity,
suicide ideation severity and suicide attempt. Our results showed that, in comparison with
cisgender LGBQ young people in the study, TGNB young people reported a greater number of
LGBTQ-bases school stress and violence experiences [TGNB mean: 4.5 (SD: 3.2), cisgender
LGBQ mean: 2.9 (SD: 2.5); range: 0, 13]. Additionally, TGNB reports of suicide ideation and
attempt were more frequent than among cisgender LGBQ study participants. TGNB young
people overall had a suicide ideation severity of 2.4 (SD = 2.0) while cisgender young people
had a mean severity score of 2.0 (SD = 2.1), a statistically significant difference [t(587) = -
254.66, p = .011]. As for reports of suicide attempt, TGNB young people also reported
significantly more attempts with about one quarter of cisgender LGBQ young people reporting
an attempt, while over 40% of TGNB respondents had made an attempt (X2 = 20.67, p < .001).
Mediation analyses showed a fully mediated relationship between gender identity and suicide

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ideation severity through LGBTQ-based school stress and violence. Nearly one-quarter (24.9%)
of the statistical effect of gender identity with elevated rates of suicidality was mediated through
LGBTQ-based school stress and violence. As for suicide attempt, mediation analyses showed
that one fifth of the relationship of gender identity with suicide attempt was mediated through
LGBTQ-based school stress and violence in a partially mediated model.
The results of paper 2 are in line with existing research that has shown high levels of
suicide ideation and suicide attempt among TGNB students, and that have demonstrated the
protective role of safety and support on suicide and other negative mental health outcomes
(Clements-Nolle et al., 2006; Goldblum et al., 2012; Johns et al., 2019; Testa et al., 2012;
Toomey et al., 2018). For example, other recent studies have also reported suicide attempt
prevalence among TGNB young people in excess of 40% (Johns et al., 2019; Toomey et al.,
2018). Further, data outside of schools has shown that support of TGNB young people from
adults is associated with lower levels of depressive symptomatology and suicide attempt
(Hatzenbuehler, 2011; Simons et al., 2013). Other research with LGBTQ students as a whole
from within schools has shown support (i.e., Gay-Straight Alliances (GSAs)) to be an important
factor related to lower psychologic distress and lower alcohol use compared to LGBTQ students
who do not have similar support (Heck, 2015; Heck et al., 2013; Meyer et al., 2019). The results
of this study and existing research in this area suggest that developing more social support of
LGBTQ students in schools may be important to reduce TGNB adolescent suicide ideation and
attempt.
Navigating Stress and Support in Schools: Paper 3
The third paper in this dissertation utilized life-history calendar interviews of TGNB
students and their parent caregivers enrolled through a local service provider (i.e., a gender clinic

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and a support group at a Los Angeles hospital) and found three main themes through a multi-
staged standardized thematic analysis. Themes were 1) support, 2) gender minority stress and 3)
mental health. 1) TGNB youth and their parents discussed support from teachers, administrators
and other school staff, as well as from peers and existing structures at school (e.g., some schools
had guidelines on how to support TGNB students when they wanted to disclose their gender
identities at school to peers and teachers). Support in school was described as essential for
TGNB youth who were connected to needed services through supportive others like teachers and
school mental health professionals. TGNB young people also explained that school can provide a
supportive opportunity to explore and be affirmed in their TGNB identities. 2) Gender minority
stress was also prevalent in interviews, with distal and proximal gender minority stressors
frequently described by families. Proximal and distal gender minority stress discussed included
harassment and bullying by peers and adults at school, a lack of affirmative TGNB policies, and
intrapersonal feelings of low-self-worth that were discussed in relation to social isolation and a
need to conceal TGNB identities. In addition, families frequently spoke about their experiences
with negative 3) mental health including anxiety, depression, suicide ideation and suicide attempt
Families also shared on diagnosed and undiagnosed experiences of neurodivergence (e.g.
ADHD, and ASD). Some of these families shared that schools frequently recommended that
TGNB students leave their traditional school settings for alternative types of schooling.
The results of this qualitative examination of TGNB students’ experiences with schooling
add narrative understanding to existing literature, including to the findings of papers 1 and 2.
Families discussed experiences of elevated suicidality, poor perceptions of their schools’
climates, as well as the role of social support as positive and transformative. Only one other
study, to this author’s knowledge, has used qualitative methods (i.e., thematic analysis of four

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focus groups) to examine TGNB young people’s reports of their schooling. McGuire and
colleauges (2010) found that harassment was prevalent in TGNB students’ descriptions of their
schools, and that feelings of safety and wellbeing were related to harassment. Further, this study
showed that actions by schools to support TGNB students, GSAs, connections with adults, and
affirmative policies were important for study respondents to feel safe and connected to their
school places (McGuire et al., 2010).
Cross-Cutting Review of Dissertation Findings
Data from the three studies of the dissertation come from geographically disparate
samples across the U.S., including a large state-wide representative dataset from a midland
region of the U.S, a dataset representative of the clientele of a national LGBTQ youth-focused
suicide crisis hotline, and from a regionally drawn small purposive sample of medically gender
transitioning TGNB youth. Taken as a whole this data deepens allied education professionals’
understandings of the experiences of TGNB students and allows for some generalizations
regarding their experiences given that measurement across the studies focused on similar
questions of school stress and support. Results provide a cohesive picture that corroborates long
standing observations that TGNB young people encounter stress and violence that begin early in
their lives (Stotzer, 2009). Data across studies further corroborates recent literature showing that
educational institutions are sites where TGNB young people encounter violence that is related to
their mental health outcomes (Hatchel & Marx, 2018; Russell et al., 2011; Toomey et al., 2018).
Data across the three studies also leave room for hopefulness, given the proportion of TGNB
students in the two empirical studies that did not report various types of violence, and given the
qualitative narrative that TGNB students and parents provided on their resilience and related

123
support from adults and peers at school. The following section will review findings across the
three dissertation studies.
School Violence. A primary objective of this dissertation was to report on the prevalence
of TGNB students’ experiences of violence at school. In studies one and two TGNB adolescents
reported increased prevalence of school violence. For example, in study one transgender students
had higher odds of having been in a fight or having been bullied compared with cisgender youth,
and in study two, TGNB youth in the sample reported significantly more bullying and fighting.
However, the proportion of fighting and bullying reported by TGNB students in comparison to
peers in studies one and two differed. In study one, nearly 60% of TGNB students reported
having been bullied, while in study two only 31.6% of TGNB students reported the same. The
reason for this wide disparity in reports among the two samples is not clear, though other factors
may help to explain these proportional differences including the differing geographic locations
from which the samples were drawn (i.e., a midland U.S. state and a suicide crisis hotline), and
differently worded questions on violence and gender identity in each study. These cross-study
findings highlight a need for continued exploration to understand the true prevalence of school
violence among TGNB students and illustrate a need for standardized measurement tools for
both school violence experiences as well as gender identity. Nonetheless, these two studies along
with the many narratives of distal gender minority stress reported in study three serve to
demonstrate that school violence is common for TGNB young people and requires the urgent
attention of allied education professionals.
Teacher Support and Inclusive Curricula. Studies two and three provide data on
TGNB students’ perceptions of their teachers as either supportive or unsupportive. For example,
study two asked respondents if their teachers were unsupportive of them because of students’

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LGBTQ identities, and if LGBTQ content was included in their curricula. One quarter of TGNB
students said that their teachers were unsupportive, and nearly 70% said that LGBTQ topics were
not included in their classrooms whatsoever. Narratives of TGNB students in study three
illustrated the experience of such findings in the lives of TGNB individuals. Most youth in study
three shared that at one point in their lives they had teachers who did not support or affirm their
needs, and at times had teachers who were openly hostile towards them (e.g., by intentionally
using incorrect gender pronouns to refer to them), all of which are experiences corroborated in
international school-based literature (Smith & Payne, 2016; Wernick et al., 2014; Zotti et al.,
2019). Additionally, youth in study three reported that there was a lack of awareness or inclusion
in their curricula on the specific needs of TGNB people. For example, many TGNB youth felt
that their sexual health questions were disregarded in the health courses that they took and that
they were often left to seek inclusive sexual health education outside of their schools. These
findings may help to explain the school climate perceptions of TGNB students reported at a state
level in study one. In the first study, TGNB students had lower odds of reporting that finishing
high school was important and were less likely to participate in extracurricular activities. Taken
as a whole, these findings suggest that schools across the U.S. should consider ways to
incorporate LGBTQ people’s experiences in curricula and support and train teachers in the
affirmation of TGNB students.
The Role of GSAs. In standing literature GSAs have been recommended as important
sources of social support that are beneficial to LGBTQ students’ mental health and wellbeing
(De Pedro et al., 2018; Heck, 2015; Heck et al., 2013). Data from the qualitative study is aligned
with these previous findings. For example, youth in the third study frequently discussed GSAs,
along with other extracurricular activities including sports and clubs, as sources of support that

125
offered peer and teacher social support, and opportunities for leadership and community
participation which were related to pride in one’s self and the LGBTQ community. As such,
GSAs are likely important for allied health and education officials to consider for practice and
policy interventions in schools. This is particularly important given consideration of findings in
paper one whereby TGNB students were less likely to participant in extracurricular activities
than their cisgender counterparts. Exploration and remediation of factors related to these
students’ reduced participation in extracurricular activities are needed given GSAs’ demonstrated
role in improving mental health. However, given limited understanding overall of rural LGBTQ
students’ experiences, and one study suggesting that LGBTQ students in rural California schools
with a GSA may feel less safe, this recommendation should be approached with caution (De
Pedro et al., 2018; Fisher et al., 2014). Regional culture categorized by more LGBTQ-focused
services and acceptance in the social ecological environment may be more indicative of
salubrious outcomes among TGNB students in a school with a GSA then compared with TGNB
students in schools that are in less LGBTQ-affirming ecological environments (Fisher et al.
2014). More research on GSAs by regionality is indicated given these findings.
Social Isolation and Leaving School. Finally, an important and emergent finding across
studies two and three is related to students’ reports of isolation, and that they had to leave or
change schools because of their minority identities. In study two, nearly 60% of students said
that they were socially isolated at school because of their LGBTQ identities, and 13.7% of
TGNB students said that they had to leave or change schools due to their LGBTQ identities. In
study three’s qualitative findings, many students reported social isolation to protect from gender
minority stress from peers and adults at school. Students in this study also shared that they
needed to change schools due to issues with lack of gender identity affirmation and/or mental

126
health supports. Findings suggest that these experiences may be widespread for TGNB young
people but given the small sample sizes of studies one and two where these experiences were
reported, and a general lack of attention paid to social isolation and school changes by students
in the TGNB adolescent literature research in this area is especially needed.
In whole, the results of the three studies provide a cohesive picture of the experiences of
TGNB students. The first epidemiological study establishes that, at a state level, violence and
poor perceptions of school climates are prevalent among TGNB students, the second study
provides a subsequent examination revealing the extent to which reports of school-place violence
and poor perceptions of school climate help to explain high levels of suicide ideation and suicide
attempt amongst TGNB students. The third study then provides weighty qualitative narratives
that illustrate how these experiences play out in the day-to-day lives of TGNB young people and
give a clear sense that supportive adults and school-places can be positive in these students lives.
In total, these results provide evidence that the reduction of school violence and the promotion of
TGNB affirmative schools characterized by social support at multiple social ecological levels
may be helpful to TGNB students’ wellbeing.
Implications for Future Research, Policy and Practice
Reviewed literature and the results of this dissertation highlight the important role that
schools can play in influencing trajectories of health and wellbeing for TGNB students. This
dissertation demonstrates an urgent need for health and education professionals to develop
TGNB affirmative school places in order to achieve meaningful improvements to their mental
health as a whole. Findings and the conceptualizing and causal theoretical frameworks of this
dissertation, that is, gender minority stress theory and the school violence heuristic of Astor and
Benbenishty (2018) are helpful tools that inform implication for practice and policy work as well

127
as future research. These frameworks suggest that changing circumstances in the social
environment of TGNB students that predispose them to targeted harassment are essential and
necessary alongside individual and group practice to develop social support of TGNB students
experiencing stress.
Practice Implications
Systematic review of literature from 1997 to 2017 and the findings of this dissertation
suggest that social support of TGNB students is essential to achieve positive gains to their mental
health (Valentine & Shipherd, 2018). Methods to achieve this end include training for teachers
and psychoeducation of students about human gender and sexuality diversity. Multiple studies
have shown a lack of understanding of the needs of TGNB people and students, and a yearning
of educators to better equip themselves to support TGNB students (Smith & Payne, 2016;
Wernick et al., 2014; Zotti et al., 2019). When some teachers at a given school are educated on
the needs of TGNB people and trained on how to support and affirm them, then others (i.e.,
teachers and students) at school are also more likely to support TGNB students as well (Wernick
et al., 2013, 2014). Further, GSAs (i.e., gay-straight alliances or LGBTQ student coalitions) can
provide psychoeducation and support to TGNB students in schools and are worthwhile
interventions for education professionals to implement at their schools and within their districts
(Heck, 2015; Heck et al., 2013; Marx & Kettrey, 2016). Additionally, the findings of this
dissertation’s qualitative study align with emerging literature that shows a higher prevalence of
neurodivergence among TGNB young people compared to the general population (Lehmann &
Leavey, 2017; Mahfouda et al., 2019; Thrower et al., 2020). These results should be considered
with great caution given a strong need for future rigorous research in this area, and do not
establish evidence of the experiences of TGNB young people at the intersection of

128
neurodivergent experience. Allied education professionals need to assess and provide services to
TGNB young people who may be more likely to present with symptoms of neurodivergence with
dignity and respect and should be aware of distinct mental health and gender identity needs while
not allowing one to preclude or write-off the other.
Review of Evidence-based Policy Implication at Multiple Social Ecological Levels
Law and policy are important tools to promote justice and affirmation of TGNB students
and can have wide-ranging effects on youth in schools (Lewis & Kern, 2018). The individual and
group practice interventions of allied education professionals must go hand in hand with law and
policy interventions that target structural factors in order to affect TGNB student health and
wellbeing. Research has demonstrated that individual practice with LGBTQ individuals can only
gain so much therapeutic traction in the absence of structural changes that reduce minority-
targeted stigma (Hatzenbuehler et al., 2013). In the absence of structural change intervention,
social support interventions alone are likely to see returns to pre-intervention levels of negative
mental health for minority populations (Hatzenbuehler et al., 2013). Thus, professionals charged
with protecting the health and wellbeing of TGNB students should work to advance policies that
dictate the development of affirmative school structures for TGNB students and that make the
protection and affirmation of TGNB students legally defensible.
The school social ecological perspective used to conceptualize this dissertation
challenges allied health and education professionals to promote evidence-based policies at every
social ecological level including at the school, municipal, district, state and federal levels (Astor
& Benbenishty, 2018). Following is a short review and discussion of some evidence-based
policy recommendations at these varying social ecological levels. For at least a decade LGBTQ
student safety and health experts have discussed four primary areas of evidence-based policy

129
interventions that are likely to lead to greater affirmation and health of TGNB students.
Specifically, these areas for policy work include, 1) advocating for the enumeration of anti-
LGBTQ bullying and discrimination policies, 2) ensuring the inclusion of LGBTQ people’s
needs and experiences across school curricula (e.g., inclusion in sexual health education, social
studies, and ensuring the availability of LGBTQ-specific educational resources at schools), 3)
advocating for unhindered access to social-support groups such as GSAs, and 4) ensuring
comprehensive training of teachers and other adults on school grounds on LGBTQ student
affirmation including training on the implementation of policy areas 1-3, and on how to
intervene in homophobic and/or transphobic bullying (Russell et al., 2010).
Enumerated Anti-LGBTQ Bullying and Discrimination Policies. School
professionals should work to develop and pass enumerated anti-LGBTQ bullying and
discrimination policies that protect LGBTQ students at all social ecological levels (Day et al.,
2019; Meyer et al., 2019; Russell et al., 2010, 2016). Such policies set the foundation for schools
and actors within schools (i.e., students, teachers, administrators and school mental health
professionals) to block discriminatory behaviors and to ensure student safety. These policies lead
to reductions in LGBTQ-targeted bullying and harassment and increase the likelihood that
teachers and peers will intervene in LGBTQ-targeted bullying (Kosciw et al., 2018; Russell et
al., 2010). Policies in and of themselves will not change the culture of schools, but they are
necessary prerequisites that send a message to all at school that TGNB students are worthy and
that their rights are legally defensible (De Pedro et al., 2018; Roberts & Marx, 2018).
Enumerated anti-LGBTQ bullying and discrimination policies have been enacted at local
municipal and state levels across the U.S. For example, the States of Illinois (Prevent School
Violence Illinois), New York (Dignity for All Students Act) and Massachusetts (Act Relative to

130
Bullying in Schools) have enumerated anti-LGBTQ bullying and harassment policies (Russell et
al. 2010). Many other states have not explicitly named LGBTQ students as protected from
targeted bullying and discrimination (Lewis & Kern, 2018). Policy advocacy is warranted to
enumerate anti-LGBTQ bullying and harassment statues at social ecological levels where such
policies are presently absent including for those states where such enumerated policies do not
exist (e.g., Texas, Ohio, and Indiana), or where they have been barred given existing statues (i.e.,
Missouri and South Dakota) [Movement Advancement Project (MAP), n.d.]. In states where
such policy is absent or has been barred, advocacy at the school, school board, and municipal
level are warranted to enumerate TGNB protective policies, or to pave the way for such policies
in the future.
Inclusive Curricula. Policies that ensure the inclusion of LGBTQ students’ needs and
experiences in curricula are important to create positive perceptions of school climate among
TGNB students (Gowen & Winges-Yanez, 2014; Pedro et al., 2016). In this dissertation data,
TGNB students reported being unable to access inclusive sexual health education that was
representative of their identities, reported that they felt unsafe, and that they did not belong at
their school places. Including TGNB people’ histories and experiences in coursework can serve
to send messages that TGNB students are worthy of respect, and that they are normal (Pedro et
al., 2016). Policies that ensure the inclusion of LGTBQ history (e.g., teaching about gay
politician Harvey Milk, or Latina transgender activist Sylvia Rivera in social studies) and that
require TGNB inclusive sexual health education in education codes are helpful policy
interventions for which legislation that can be used as a guide exist (Kosciw et al., 2018;
Vecellio, 2012). One such example of policy that meets this end is the FAIR Education Act,
which was signed into law in the State of California in July of 2011 (Vecellio, 2012). This act

131
requires the representation of LGBTQ people’s experiences in the state’s social science
curriculum and prohibits the State Board of Education from adopting discriminatory martials or
instructional practices. Similar legislation with appropriate adaptations given regional
characteristics should be considered by allied education professionals to support TGNB students
at state municipal and school board levels.
Training. Policies that provide for systematic training for education professionals on
how to utilize enumerated anti-LGBTQ bullying policies to protect students, on the creation and
implementation of inclusive curricula, and on the affirmation of TGNB students are warranted
and will likely affect TGNB students’ positive wellbeing in schools (Swanson & Gettinger,
2016). An example of federal policy introduced to both chambers of the U.S. Congress includes
the Real Education for Healthy Youth Act which would ensure funds for teacher training and
grants for comprehensive sex education, in addition to requirements for sex education to be
inclusive of LGBTQ young people, and to prohibit federal funding of programs that exclude or
discriminate against LGBTQ people [Human Rights Campaign [HRC], 2020a).
Social Support Groups Access. GSAs are promising school social support groups that
are associated with positive mental health and safety for LGBTQ youth in most studies that
examine them (De Pedro et al., 2018; Heck, 2015). Policy that allow adults and students at
schools to form and hold GSA meetings should be considered at every social ecological level
and across geographic areas. Challenges to students’ rights to convene GSAs have been made in
the U.S. federal court system with multiple cases finding that students have a right to convene
GSAs guaranteed through the first amendment of the U.S. Constitution which ensures freedom
of speech. Allied education professionals developing TGNB affirmative schools can use

132
knowledge of these cases to support the formation and rights of GSAs to meet at schools without
obstruction.
Discussion on Federal Policy Protections and the U.S. Court of Appeals.
Though federal policies protecting TGNB students’ right to education are limited, they
are likely to have wide ranging and comprehensive positive impact on TGNB students and their
health (Lewis & Kern, 2018; MAP, n.d.). Allied education professionals engaging in policy work
should advocate for federal level policies that specifically protect TGNB students. However,
given conservative social values and political administration in the U.S., implementation of
federal level LGBTQ student protections and mandates for schools to follow evidence-based
supportive practices may be difficult to achieve (Lewis & Kern, 2018). For example, the present
political administration has taken steps to overturn previous federal policy interpretations that
directed schools to protect and affirm TGNB students without reliance on evidence (Lewis &
Kern, 2018; Smith & Redden, 2017). Nonetheless, advocacy for policy at the federal level to
protect TGNB students should be actively pursued by allied education professionals. One
example of an impactful federal policy that has been passed in the U.S. House of Representatives
but not the U.S. Senate is the Equality Act, which would amend standing civil rights laws
including the Civil Rights Act of 1964 to explicitly provide protections based upon sexual
orientation and gender identity (HRC, 2020b). The Equality Act would federally prohibit
discrimination against TGNB students in educational institutions and is a warranted policy
objective.
Further, the U.S. Courts of Appeals has been important in extending or curtailing federal
protections of TGNB students under Title IX of the Patsy T. Mink Equal Opportunity in
Education Act which bars discrimination based upon sex in U.S. educational institutions (Lewis

133
& Kern, 2018, Roberts & Marx, 2018). This act, though not explicit in regard to protections for
TGNB students has been interpreted differently among cases brought to the U.S. Courts of
Appeals. For example, the U.S. Court of Appeals for the Ninth District has found that Title IX
protections do extend to students based upon gender identity, while the Tenth District has found
that they do not (MAP, n.d.,). At present The Supreme Court of the United States has declined to
determine whether Title IX protections extend to students based upon actual or perceived gender
identity. Allied education professionals should advocate for the expansion of protections of
TGNB students through Title IX and use the nuances of existing rulings to argue for the adoption
of supportive policies described above across social ecological levels (Lewis & Kern, 2018).
Choosing Policies to Support TGNB Students.
School social workers and other allied education professional should use caution in
reviewing and selecting policy interventions for their schools, school districts, municipalities,
and at state and federal levels. Policy can have harmful and unintended consequences which may
negatively impact students and run counter to policy workers initial objectives. For example,
Roberts & Marx (2018) highlight and critique the pitfalls and failings of individually targeted,
punitive policies such as the federal anti-discrimination and harassment statues established in the
Safe Schools Improvement Act of 2015. This act informs school professionals of the harms of
bullying and harassment but offers no evidence-based practices or policies to protect student
safety through structural changes. Instead, the act directs school officials to reduce bullying and
violence on individual campuses and sets up a punitive surveillance structure that motivates
school leaders to underreport violence and expel students most at risk to engage in violence.
Preferable policies attempt to address structural deficiencies that create risk for marginalized
students (Roberts & Marx, 2018). When choosing policies to implement allied education and

134
health professionals should rely on evidence and engage in critical policy analyses to attempt to
understand the potential consequence and impact of pursued policy interventions.
Dissertation Limitations and Future Research
Continued examination of the school-based experiences and outcomes of TGNB young
people is urgently needed given the alarmingly high rate of suicide ideation and attempt among
this group of socially stigmatized young people and the current gaps in understanding of their
schooling experiences (Toomey et al., 2018). First, future research should continue to
conceptualize explorations of TGNB students’ school-based outcomes using the gender minority
stress framework which provides a temporal and causal theory on how social factors impact
intrapsychic experiences and ultimately poor mental health like suicide. Research that uses this
framework can provide evidence of the most salient and feasible contextual factors for mental
health intervention (White Hughto et al., 2015). To achieve this end, future research must use the
best available measures to holistically identify and measure school-based phenomena including
school climate and school violence. At present, for example, measures of school climate and
school violence (including those used in this dissertation) vary widely across studies and more
standardized measures will grant the opportunity for researchers to make comparisons across
schools, districts and regions, and to more accurately understand the relationship of school
climate and violence with TGNB mental health outcomes (Astor & Benbenishty, 2018;
Benbenishty et al., 2018; Thapa et al., 2013). Furthermore, two empirical studies in this
dissertation relied on secondary data analyses for which the measures of gender identity did not
follow best practices for gender identity assessment such as those outlined by The GenIUSS
Group (2014). Comprehensive measures of gender identity and expression have not been

135
systematically used in data with young people in school settings and efforts should be made to
assess gender identity and expression comprehensively in research with youth.
Further, while this dissertation was able to provide some disaggregation across sexual
orientation and gender identity more research that is attentive to intersectionality and enrolls
sufficiently large samples to disaggregated students by gender identity are needed (for examples
of research that is cognizant of intersectionality see: Hatchel & Marx, 2018; Kattari, Atteberry-
Ash, et al., 2019; Kattari, Walls, et al., 2019; Toomey et al., 2018). While this dissertation was
able to provide some disaggregation of gender identity (e.g., paper 1 examined TGNB students’
and students who were questioning their gender identities in comparison with cisgender peers),
research that examines transmasculine, transfeminine, and gender nonbinary peoples’
relationships to mental health outcomes and schooling are needed.
Additionally, the results of this dissertation cannot be generalized to all TGNB
populations and no causal inference can be made given the cross-sectional nature of the data in
each of the three studies. Further, it is also important to be cautions in extending the
generalizations of the present data given the sampling frames of each of this dissertation’s three
studies, which relied on geographically disparate populations. Future research that observes
changes to school climate and school violence, and TGNB students’ outcomes with whole-
school comparisons, across large geographic areas of the U.S. and globe over time are needed
(Benbenishty et al., 2018; Moore et al., 2020). Such studies are needed to inform the
effectiveness of school climate improvement recommendations, for example by demonstrating
empirically if school climate interventions (e.g., enshrining protective policies, establishing a
GSA, training teachers on LGBTQ affirmative practices, etc.) reduce suicidality among TGNB
students from baseline to follow-up.

136
Conclusion
This dissertation sought to bring awareness to the experiences and needs of TGNB
students in the United States and to address the epidemic of violence and suicide ideation and
attempt among this population. Schools are fundamental institutions in the United States that
send messages to young people about what and who society deems valuable and worthy
(National Commission on Social, Emotional, & Academic Development, 2019). All youth
regardless of gender identity are worthy of healthy development and safe supportive schooling.
At present, results of this dissertation show that TGNB youth often encounter violence and are
lacking social support on their school campuses. Further, qualitative results showed that some
TGNB students are sent messages that they are not able to be schooled in traditional settings due
to their specific gender-based needs. Nonetheless, data also showed that social support from
peers, teachers, administrators and through policy and structures at school can be transformative
and positive for TGNB students. Allied education professionals must intervene through policy,
practice and research to improve schools across the United States to affirm TGNB and all
students.

137
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Asset Metadata

Creator Klemmer, Cary Leonard (author)

Core Title A mixed-methods examination of transgender and gender nonbinary students’schooling experiences: implications for developing affirmative schools

School Suzanne Dworak-Peck School of Social Work

Degree Master of Social Work / Doctor of Philosophy

Degree Program Social Work

Publication Date 07/01/2020

Defense Date 04/21/2020

Publisher University of Southern California (original), University of Southern California. Libraries (digital)

Tag gender minority stress,LGBTQ,mixed methods research,OAI-PMH Harvest,school climate,school violence,TGNB,transgender and gender nonbinary

Format application/pdf (imt)

Language English

Contributor Electronically uploaded by the author (provenance)

Advisor Goldbach, Jeremy Thomas (committee chair), Blosnich, John (committee member), Ferguson, Laura (committee member)

Creator Email caryklemmer@gmail.com,cklemmer@usc.edu

Permanent Link (DOI) https://doi.org/10.25549/usctheses-c89-323173

Unique identifier UC11673228

Identifier etd-KlemmerCar-8630.pdf (filename),usctheses-c89-323173 (legacy record id)

Legacy Identifier etd-KlemmerCar-8630.pdf

Dmrecord 323173

Document Type Dissertation

Format application/pdf (imt)

Rights Klemmer, Cary Leonard

Type texts

Source University of Southern California (contributing entity), University of Southern California Dissertations and Theses (collection)

Access Conditions The author retains rights to his/her dissertation, thesis or other graduate work according to U.S. copyright law. Electronic access is being provided by the USC Libraries in agreement with the a...

Repository Name University of Southern California Digital Library

Repository Location USC Digital Library, University of Southern California, University Park Campus MC 2810, 3434 South Grand Avenue, 2nd Floor, Los Angeles, California 90089-2810, USA