Research on Promising Strategies for Trauma-Responsive, Affirming Care

Bias and Discrimination Impact LGBTQIA2S+ Young People’s Experiences With Care

LGBTQIA2S+ young people experience bias and discrimination in numerous forms—ranging from interpersonal to structural—that can discourage them from seeking care in the future.^29-31 Experiences with biases sow feelings of mistrust, thus impeding these young people’s access to high-quality services.^32,33 Access is further restricted for young LGBTQIA2S+ people of color who experience cissexism, heterosexism, and racism at interpersonal and structural levels.^34,35

On the interpersonal level, providers can create unsafe environments and undermine access to competent care by making assumptions about young people’s pregnancy and sexually transmitted infection (STI) risk based on their presumed gender, sexuality, and/or race (and that of their partners); refusing to use correct names and pronouns; and/or hypersexualizing patients of color.^36,37 To promote safer environments and equity in access to care, providers should listen to young people and tailor sexual and reproductive health services to their needs rather than rely on assumptions about their body parts and those of their partners to determine the appropriate services.

At the structural level, the reproductive health care system is often mislabeled as “women’s health care” to the exclusion of trans and gender-nonconforming people. Furthermore, the system’s history of nonconsensual experimentation and sterilization of people of color continues to negatively impact experiences with care.^38,39

Research suggests that the incorporation of practices that affirm LGBTQIA2S+ identities is beneficial for all young people, even for those who don’t identify as LGBTQIA2S+.⁴⁰ Addressing bias and discrimination against LGBTQIA2S+ young people is necessary to mitigate the risk of further trauma and marginalization.^41,42

Strategies and Considerations for Providing Trauma-responsive, Affirming Care

Providing trauma-responsive, affirming care requires an individual and organizational commitment to inclusivity and an understanding of how power structures impact a person’s experience with care and their subsequent needs.⁴³ To integrate trauma-responsive and affirming practices, research suggests that organizations must:^44-47

1. Align organizational culture and accountability structures with trauma-responsive, affirming care principles;
2. Address poor job quality and related workforce issues;
3. Obtain cross-agency buy-in and competency by regularly training all levels of staff and administrators in affirming care principles and practices; and
4. Facilitate cross-systems collaboration.

Below, we summarize the literature on professional recommendations and evolving best practices for creating organizational settings that are culturally responsive, affirming, trauma-informed/responsive, and equitable for LGBTQIA2S+ populations.

Align culture and systems with trauma-responsive affirming care principles.

For many youth-serving organizations, providing trauma-responsive affirming care requires substantial shifts in organizational policies and culture. Research highlights the need to transform organizational environments from those that contribute to trauma to those that promote healing by prioritizing safety and relationships.⁴⁸ Organizations can create a greater sense of emotional safety by developing and enforcing transparent organizational and nondiscrimination policies that allow self-identification of sexual, gender, and racial identity; detailing standards of care; and providing support on navigating legal and insurance challenges for LGBTQIA2S+ young people.^49-51 Overtly gendered spaces can elicit discomfort among trans and gender-nonconforming people, so incorporating gender-neutral décor, visible cues like inclusive artwork and handouts, and gender-neutral bathrooms can foster a greater sense of physical safety by showing LGBTQIA2S+ young people that their needs were considered in creating the space.^52-54

When program priorities clash with trauma-responsive affirming care principles, they constrain the ability of direct care staff to act in affirming ways. For trans and gender-nonconforming youth experiencing homelessness, insistence on sex-segregated shelters is inherently non-affirming and alienates them from receiving further services.⁵⁵ Within juvenile justice systems, for example, conflicting objectives of rehabilitation and deterrence can impede any efforts to introduce trauma-responsive affirming care practices.⁵⁶ Organizations must first address systems-level barriers that prevent staff from providing trauma-responsive affirming care before mandating new policies or trainings.⁵⁷ A study of child welfare supervisor perspectives on trauma-responsive practices found that task-focused accountability measures and supervision practices hindered successful implementation. This suggests a need to instead align accountability and supervision approaches with trauma-responsive affirming-care principles—for example, by encouraging supportive feedback and guidance for direct care workers as they work to implement these practices.^58,59

Address poor job quality and workforce issues.

Creating a supportive environment for direct care workers is key to developing a workplace culture that facilitates affirming care by prioritizing safety and relationships. Providing supportive jobs with opportunities for career advancement can reduce highly prevalent workforce-related barriers to affirming care, such as staffing shortages, turnover, burnout, and vicarious trauma.^61-63 In many cases, supporting workers requires additional funding to make affirming care a reality. Common constraints like high caseloads and competing priorities can hinder the ability of staff to build meaningful relationships.⁶⁴

LGBTQIA2S+ people often seek out LGBTQIA2S-identified providers to improve their experience with care.^65,66 Actively recruiting and hiring LGBTQIA2S+ personnel, health specialists, and peer advocates with intersectional marginalized identities and lived experience can also help build culturally responsive environments for LGBTQ+ populations.^67,68 All professionals should engage in personal and interpersonal anti-stigma work to address bias through education on LGBTQIA2S+ experiences. Their education must be expansive to prepare them to provide care to young people who hold multiple marginalized identities.^69-71 In addition to individual education to address bias, providers should support young people’s agency by allowing them to make decisions about their care and treatment plans.^72,73

Obtain cross-agency buy-in and competency through regular trainings.

Because successful implementation of affirming care principles requires addressing barriers at all organizational levels, research indicates that all levels of staff and administrators should engage in training—including anyone who might contact young people, as well as those whose decisions constrain the ways in which direct care staff can engage youth.^74,75 Trainings that are led by those with lived experience in the child welfare and juvenile justice systems, homelessness, or disconnection from school and work can provide professionals with additional perspectives and practice recommendations.⁷⁶

Workers often encounter administrative and organizational barriers that can prevent full implementation of affirming and trauma-responsive care principles and practices. Training leaders and supervisors before training direct care staff allows these leaders to champion the approach and to lend organizational support instead of obstructing progress.^77,78 Providing training at both initial onboarding and on a regular basis ensures that organizations can keep up with evolving standards.⁷⁹

Facilitate cross-systems collaboration.

Developing cross-systems training can help standardize the language, skills, and strategies that service providers use across different fields.⁸⁰ The literature highlights strategies for facilitating cross-systems work, including assigning young people a team coordinator or systems-navigating advocate, developing strong referral networks, and participating in LGBTQIA2S+ community events.^81-83 A key aspect of trauma-responsive affirming care is for providers to recognize how the challenges facing a particular young person are often embedded within the challenges facing the broader communities to young people belong. Hence, organizations striving to provide trauma-responsive affirming care should also consider how they can better address structural inequalities and community-level needs while also valuing community-level assets—for example, by supporting advocacy efforts supported by LGBTQIA2S+ communities, such as Medicaid expansion and family acceptance therapy.^84,85

Addressing trans and gender-nonconforming young people’s needs.

When providing trauma-responsive affirming care to LGBTQIA2S+ young people, health care providers must ensure that all young people are included. Health services advertised as LGBTQIA2S+ umbrella services don’t always meet the needs of trans and gender-nonconforming young people due to a lack of trans-specific knowledge and experience.⁸⁶ Many trans and gender-nonconforming young people instead rely on peer support to access health services and information that address their needs and experiences.^87,88 Trans and gender-nonconforming young people—especially those who are medically transitioning—have unique health concerns, so providers must understand how gender-affirming hormone therapy affects sexual and reproductive health to provide accurate information on safer sex and STIs, contraceptive options, and fertility preservation.^89,90 For example, vaginal dryness is a common effect of testosterone hormone therapy, which can make pap smears more painful.⁹¹ One component of providing trauma-responsive affirming care for a young person on testosterone could be to prescribe a topical estrogen to apply a few weeks before a pap smear to increase natural lubrication and decrease potential discomfort.⁹² Providers should ground their care in individual transition goals, however, as many young people may have goals for their bodies outside of adherence to the gender binary.⁹³

Research Gaps

Much of the literature on providing trauma-responsive, trauma-informed, affirming, and/or culturally competent care to young people with experience in the child welfare and juvenile justice systems, homelessness, and/or disconnection from school and work does not specifically address the experiences of LGBTQIA2S+ young people in accessing sexual and reproductive health services. These young people’s experiences differ from those of their cisgender, heterosexual peers, and more research is needed to better understand the interaction between 1) sexual and/or gender identity; and 2) experience in the child welfare and/or juvenile justice systems, with homelessness, and/or with disconnection from school and work—and how this interaction impacts young people’s sexual and reproductive health care needs. For example, much of the literature on trans and gender-nonconforming young people in sexual and reproductive health settings focuses on HIV risk or on clinicians providing care to these young people; however, more research is needed on the actual experiences and perspectives of trans and gender-nonconforming young people, particularly those who experience the child welfare and/or juvenile justice systems, homelessness, and/or disconnection from school and work.^94-96 Additionally, program efforts to align culture and systems with trauma-responsive affirming care principles should consider youth’s multiple identities and experiences (e.g., related to their age, income, geography, immigration, language, etc.) and how those might interact with gender identity to more holistically address people’s needs.

Future research priorities should also include more implementation research to test the quality of trainings, as well as the implementation and quality of cross-system collaborations, including areas for improvement. Additionally, further research is needed to understand the multiple intersecting experiences of youth and how cross-system collaborations and trainings can better address multiple identities and experiences. As mentioned in the Methods section, the professionals we spoke with expressed an interest in healing-centered care due to its alignment with youth-centered and strengths-based approaches. More research is needed on this approach to care, particularly for LGBTQIA2S+ young people; young people with experience in the child welfare and juvenile justice systems, homelessness, and disconnection from school and/or work; and in medical and social services settings more broadly. Finally, incorporating the voices of youth, service providers, and other professionals who support LGBTQIA2S+ young people is critical to the success of these research activities.