A WPATH GEI Advanced Mental Health Course

Intersectionality: Clinical Concerns in

Working with Ethnic Minority
Transgender Clients & Their Families
By Dr. Wallace Wong, R. Psy.
Montreal, Quebec, Canada – Friday, 16 September, 2022
Background and History
• In a letter written in 1544 to João de Albuquerque, the Portuguese
bishop of the Indian state of Goa, De Paiva wrote:
“Your Lordship will know that the priests of these kings are generally
called bissus. They grow no hair on their beards, dress in a womanly
fashion, and grow their hair long and braided; they imitate [women’s]
speech because they adopt all of the female gestures and inclinations.
They marry and are received, according to the custom of the land, with
other common men, and they live indoors, uniting carnally in their
secret places with the men whom they have for husbands …”
 • There is a long history of gender pluralism being practice in different countries and
cultural groups.
• Gender pluralism is the notion that include all sex/gender identities within the
realm of plausible identities (e.g., unusual ,marginalized, and fluid identities)
• The fact that transgender shamans have been accorded status not just in Indonesia
but across much of Southeast Asia is a powerful indication for the historical
contingency of what many today in the West take to be essential about gender.
Background • For Example:
• Malaysia: Sida-sida
and History •
•
Burma: Nat kadaw
Indonesia: Bissu
• Hawaiian: RaeRae/Mahu
• Historically in Hawaiian culture, every one person had a role, from
chiefs to caregivers. In the past, mahu’s were valued and
respected, seen as caretakers, healers, and teachers of ancient
traditions.
 • Across Asia, Polynesia, Indigenous people
today, there is a severe constriction of
gender and sexual plurality compared to a
hundred years ago.
• All these changed when the western religion
and colonialism took place across different
Background regions.
and History • The arrival of the missionaries and Christian
morality resulted in the emergence of a new
moral and sexual order.
• Homosexuality became illegal. For example,
Southeast Asian nations such as Singapore
and Malaysia when they were colonized by
the British.
Current Changes
• Today, Malaysia continues to criminalize same-sex intercourse, while
Singapore legalized female homosexuality in 2007.
• Anti-transgender protests are also happening right now in Southeast
Asia. Protestors frequently ‘blame’ the West for introducing these
things.
• While homosexuality is not criminalized in Thailand, Laos, Cambodia,
Vietnam, and The Philippines, and Indonesia, apart from Aceh,
discrimination against LGBTIQ people, as well as domestic and public
violence remains high.
• They are integrated into local professional and cultural life and are
accepted, as long as their sexuality remains unspoken and invisible.
 • The Philippines, Brunei, also do not allow for gender
reassignment surgery.
• The Supreme Court had the chance to decide on this
Some issue in the case of Rommel Jacinto Dantes Silverio
vs. Republic of the Philippines, G.R. No. 174689, 22
Progress October 2007.
• Name and Sex Cannot be Changed without Law
Current Changes
Silverio's case opens a window for a law to recognize transgender
individuals.

A gender recognition bill yet to be released, which allows the change

in the markers in birth certificates and other government
documents.
However, the draft bill only covers those transgender individuals
who have gone through the surgery.
Current Changes
• About 80 percent of Filipinos are Roman Catholic, and the church’s
teachings often dominate public life in the Philippines. Aurora
Almendral (April 29, 2018)
• Dominated by conservative morals taught by the Roman Catholic
Church, the Philippines is also one of Southeast Asia’s most tolerant
countries toward gay, lesbian, bisexual and transgender people. And
lawmakers are taking steps to ensure national legal protections that
would penalize discrimination against them.
 • Still, 41 transgender people were killed in
the Philippines between 2008 and 2016, the
highest rate in Southeast Asia, according to
the Trans Murder Monitoring Project of the
organization Transgender Europe. A
study published in The Philippine Journal of
Current Psychology in 2014 found that gay, lesbian,
Changes bisexual and transgender Filipinos were
twice as likely to contemplate suicide as
their heterosexual peers.
• Overall, participants (139)who reported
higher levels of discrimination, stigma, and
violence Arjee J Restar 2021
Estimated Percentage of the Population by Race and Ethnicity for the
Adult General Population and Transgender-Identified Adults in US (2015)

Chart Title
70%

60%

50%

40%

30%

20%

10%

0%
White African-American Hispanci/Latino Other Race/Ethnicity
Adult General Pop. Trans. Adults
Statistics Canada

% OF TRANS AND NB PEOPLE (2022/4/27)

% of Trans and NB people (2022/4/27)

Intervwar Genderations (1945 and earleir)

Baby Boomers (1946 to 1965)

Millennials (1981 to 1996)

Gen Z (1997 to 2006)

0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9

Indigenous peoples in Canada
• Suicide is the leading cause of injury-related death among children in youth in BC

• Indigenous peoples experience higher rates of suicide than non-Indigenous people in Canada.

• 19 Suicide deaths were children/youth between ages of 10 and 18 years in 2018

• 23% of all youth suicides identified as Indigenous

• 47% of non-binary reported self-harm in the past year

• Inuit communities experience highest rates suicides of any group in Canada at 72.3 per
100 000 individuals.
Under-Representation of Ethnic
Minorities in Canada’s Trans
Community
• Transgender persons make up .5% of Canadian
population ~ 1.8 million people (Statistics Canada,
2016).
• Despite these numbers, transgender clients from
non-Western countries are rarely seen in clinical
practice
• Transgender people from ethnic minority groups
have been found to have the highest prevalence
of suicidal attempts.
• A study done by the William Institute (2014)
found that the suicide rate for transgender
people who are multiracial is 54%, and for those
who are Aboriginal the rate is 56%.
Reasons for Resistance
• Lack of role models in their own ethnic community
• Lack of information that is specifically for these minority groups
(mostly written in English)
• Lack of resources
• They don’t know where to, who to turn to
• Resources are only made for “white” people
• High level of stigmatization from their own ethnic/cultural group
 • Professionals lack understanding and knowledge
about ethnic values and the consequent interaction
with racist society
• Professional use traditional White/Western models
in working with this ethnic group
Clinical • Professional use western values to evaluate the
treatment success/outcome. (i.e. doing vs. being)
Issues - • Mono-cultural assumptions of mental health
Introduction • Negative stereotypes of pathology for minority life
styles
• Fail to see the impact of the linguistic factors,
environmental factors (crowd, broken home), social-
cultural factors
 Collectivistic versus
Individualistic values
Minority Stress
Clinical
Issues First and Second-Generation
Immigrants
Impact of Acculturation
 Collectivistic worldviews
prioritize the family or in-group

Collectivism • Interdependence within the group is

valued and emphasized
versus
Individualism Individualistic worldviews
prioritize personal goals and
achievements
• Asserting one’s independence is valued
and seen as an indicator of success.
 Asserting one’s authentic self may be
seen as incompatible with conforming to
the roles tied to one’s natal sex.

Collectivism & A transgender youth who comes out may

Transgender be seen as rejecting the family system
and pursuing their personal goals.
Youth
Parent quote: “Why is my child being so
selfish? Don’t they think about our family
at all?
 • Being stigmatized
• Lower social economic status
• Prejudice and discrimination
• Lack privileges
Minority • Causing extra stressors – MH and adverse
Stress health outcome,
• Prove to the world/Concealment (financially
secure, good MH, not on welfare)
 • A process in which psychosocial resources
reduce the impact of life stress
• (e.g. African American parents will teach their
children on ways to behave in a discriminatory
society)
Buffer Effects • Transgender children & youth have to
learn through trials and errors and often in
isolation
Psychosocial Challenges
• Double minority status Excluded
from both ethnic community and
LGBTQ community
• Having to choose one community
over another
• Tension/Pressure from family and
larger social group
• Internalized stigma
 • Clinicians must consider both the client’s
views on the home/host culture and their
Ethnic views on gender identity
Transgender • Internalized heterosexism: internalized
Youth as negative views on LGBTQ identities
• Internalized racism: internalized negative
Double views on racial or ethnic identity
Minorities • Acculturation model applies to these two
communities/cultures
 • First generation families tend to be more
Gap Between attached to their home culture; socialize
primarily with their cultural/ethnic
First and community.
Second • Second generation families are more
exposed to Western culture, have more
Generation social connections with people from
Western culture.
 • Different exposure to gender identity
perspectives
• Child asserting their authentic gender
identity may be perceived by parents as
1st versus 2nd disowning or abandoning their culture of
origin
Generation
• Tension/marginalization by larger social
group, family unit, and even internalized
shame.
What is Acculturation?
The process by which foreign-born
individuals and their families learn to
adopt the language, values, beliefs,
and behaviors of the new
sociocultural environment (Unger et
al., 2000)
Potential Acculturation Strategies of Ethnic Minority Transgender
Individuals
 Assimilated adolescents:
• May challenge familial norms and
Potential cultural expectations
• Adopt roles and behaviors of
Acculturation LBGTQ community
Strategies • Strong need to validate self-
concept and seek validation from
(Adapted from family
• Distance selves from or limit
Hahm & Adkins, contact with the home community
2009)
• Separated adolescents:
• Primarily invested in ethnic identity and family role
• May be stuck in the “Identity Confusion” stage
• Greater inability to disclose gender identity
• May experience greater internalized transphobia and feelings of isolation,
depression, anxiety
• May feel the need to separate from LGBTQ community due to fears of shame
or exposure
Marginalized adolescents:
• Exist in marginal spaces of both communities
• May avoid and feel uncomfortable in both communities
• Withdrawal from school and work
• Little social interaction
• May have limited access to community services due to language barriers
Integrated adolescents:
• More aware of the differences between the two cultures:
• Greater desire to bring together both cultures
• More access to social support in both networks
 • Ethnic Minority Transgender youth struggle
with establishing their authentic gender
identity
• Identity may be incongruent with BOTH norms
of the home culture and the host culture

Unique • Negative stereotypical images of ethnic

minorities (e.g., Asian being passive) within
Challenges the Western LGBT community may lead to
clients feeling as though they must distance
themselves from their ethnic background
• The adolescent client and their
parents/guardians may be at different
acculturation strategies
 • See transgender issues as western society
issues
• See transgender issues as western
propaganda (being imposed on them)
• Gay Pride
• Sex ed.
The West vs. • Fear of losing their cultural values if they
the East accept the western view on transgender
issues
• too liberal and progressive
• contradictory to and challenging their
traditional cultural values
• See it as a threat rather than a solution
 • Transgenerational trauma
• An authoritative Caucasian person telling them
what is the “right” thing to do
• Suspicious toward the western approach
• Feel powerless, thus “resist” becomes their only
The West vs. choice
• The residual effects of Colonial trauma
the East • Deja vu all over again
• Feel resentful, inferior, subordinated,
• Color codes and beauty codes
 • Experience a loss of control and feel that
their cultural values are being attacked or
undermined by the clinician
• Suspicious or wary of clinicians that appear
“liberal” or “progressive”
Families in
• May view the clinician’s opinions or
Separation or suggestions as “Western propaganda”
Marginalization targeted to their child
• May turn to biased sources reinforcing
negative views of child
• At risk of becoming more isolated and/or
insulated
 • Important for the clinician to “match” the
client and family, taking into account their
level(s) of acculturation
• Clinicians of a Western background may
have a bias towards individualism and may
unknowingly impose these views on the
Risks of Not client
“Matching” • Clinicians may encourage more
independence than the client is
psychologically ready for
• Clinicians could create further disruptions in
the family system and cause greater distress
for client
 • Therapists with similar beliefs and values
perceived as more empathic and supportive
• Decrease the likelihood of premature
termination by the family
• Increase the likelihood that the family will be
open to evidence-based assessment and
Benefits of treatment
“Matching” • Clinician serves as a model for how to gain more
understanding of, communicate with, and seek
social support in both communities
• Provide opportunities to connect families with
others from similar cultural background with
transgender youth
 • Every individual is unique, avoid generalization
• Thoroughly assess the acculturation process
between the youth and the family is a crucial
therapeutic process.
• Matching the therapist/counsellor/professional
based on the acculturation process of both parties
can make treatment more effective.
Conclusion • Examine our own cultural bias (the lenses we use to
interpret their behaviours and ‘symptoms’.
• Aware of your privileges and the authority that you
hold.
• Using systematic approaches as much as possible.
• It’s not unusual that extended family members will
be included in the work process.
 Thank you
[email protected]
Case Discussion
• Fernando is 18 years old and you have met with Fernando for 2
sessions (for self-harm, anxiety, and depression). During this session,
she came out to you that she is trans-female. Fernando moved to
Canada from Philippines when she was 5 years old along with her
parents. She told you that she has a 20 year old sister and her parents
are devoted Catholic. Both parents are working and Fernando ‘s
father is the chair person of the Filipino Society Club. Fernando wants
to come out to her parents in her next session with you, because she
was fearful about the outcome. She recalled her parents making
negative comments about LGBT people when they were watching tv.
Case Discussion
James is a 26 yo transgender man born into the Kwanlin Dun First Nation in what is now
the Canadian Yukon. His family has been rejecting of his expressing his masculine
identity. Some members of his family have been supportive, some neutral, and some
rejecting/disapproving. The same is true of family friends. He has become more isolated
since finishing his education, and he drinks a lot after finishing work. He has not started
testosterone or had masculinizing surgeries, as he wants, but presents in attire usually
perceived as masculine in public places and at his job.

Due to fear of disappointing his parents, especially his mother, he has avoided going to
possible shared public places like the Kwanlin Dun Cultural Centre. He does not go to
special events or seek Community Services he is entitled to. He has avoided social
opportunities like a recent Meet and Greet and the Kwanlin Dun First Nations Fun Day in
August.

James is very depressed, and he feels stuck. He likes his job where he feels valued. He
doesn’t want to leave where he grew up enjoying activities on the Yukon River like
canoeing and fishing. How can you help him?
Case Discussion
• Wai Tung is AMAB and identifies as female. She is 32 years old, single
and living with her parents. She is the only child and works at her
family shop. The family moved to Canada from China 15 years ago.
Wai Tung came out to her parents 5 years ago, but her parents’
attitude towards transgender people is still negative. Wai Tung wants
to start her hormone treatment. Her parents are against it. Upon
seeing her family doctor, Dr. B. Dr. B suggested Wai Tung to move out
if she is serious about this treatment, so that she can have the
freedom to make her own decision. Instead of telling her family that
she needs to move out, Wai Tung attempted suicide instead.
• How can we help Wai Tung and her family?
Case Discussion
• Asha is AFAB and he identifies as transmasculine. He is 20 years old,
and his family moved from India when Asha was 5 years old. Asha
was caught stealing men’s clothes from his neighbor's house. The
neighbor called the police and during the police inquiry, Asha came
out to his parents that he is transmasculine. His parents could not
accept Asha’s gender identity and told Asha to choose to change or
he needed to move out. Asha chose to move out and lived with his
aunt temporarily. Asha and his parents talked over the phone
multiple times a day while staying with his aunt, but he often ended
his called crying and feeling guilty for putting his family through this.
• How can we help Asha and his family?
Case Discussion
Robert is 19 years old, from Taiwan and she came to see you due to
depression and recently came out to her mother as female. When you
met with Robert, you noticed her avoiding eye contact and talking in
monotone. She told you that she did not have any friends because she
was “different and bullied.”
In your next session with Robert, she told you that she came out to her
mother and her mother and other church members forced her to go to
church where they performed exorcism rituals on her to cast out her
transgenderism.
How will you help Robert and her family?