What is trauma-responsive, LGBTQ+ affirming care?
Trauma-responsive, LGBTQ+ affirming care is a strengths-based approach to care that responds to the ways traumatic experiences intersect with gender identity and sexual orientation, as well as other identities—such as racial/ethnic identity, socioeconomic status, and immigration status—to impact a person’s needs. 16,17
Defining Trauma-Responsive, LGBTQ+ Affirming Care
We define trauma-responsive, LGBTQ+ affirming care as a strengths-based approach to care that responds to the ways traumatic experiences intersect with gender and sexual identity, as well as other identities—such as racial/ethnic identity, socioeconomic status, and immigration status—to impact a person’s needs.12,13 This definition is informed by the scientific literature and by our conversations with youth-supporting professionals and young people. When youth-supporting professionals provide trauma-responsive, LGBTQ+ affirming care, they create a safe, supportive, and nonjudgmental environment that promotes positive sexual and reproductive health (SRH).
“Each individual should be catered to according to their needs, accounting for their traumatic experiences. [Trauma-responsive, LGBTQ+ affirming care] is care that is individualized and permits vulnerability. It invites an individual to come into any space as they are, knowing that they will be connected to support and resources best for their health.”
– A systems-involved young person, responding to the question what is trauma-responsive LGBTQ+ affirming care?
Physical and emotional safety
Authentic and consistent relationships
Recognition and awareness of trauma
Putting trauma-responsive, LGBTQ+ affirming care into practice
The following scenarios can be used as practical guides for case managers who work with young people, particularly those who facilitate access to sexual and reproductive health (SRH) care or talk with young people about their sexual identities and experiences. Since young people’s gender and sexual identities can change over time and because their trauma histories might not be immediately apparent, we encourage professionals to employ these approaches with all youth.
Each scenario illustrates the application of some or all the principles of trauma-responsive, LGBTQ+ affirming care. The scenarios can be used in the context of trainings for case managers on trauma-responsive and LGBTQ+ affirming care or referenced in real time when working with clients. These scenarios should be considered starting points from which case managers can build out their engagement strategies and treatment plans with young people. The scenarios were inspired by and co-created with young people, youth-supporting professionals, and researchers with lived and/or professional experience.
Scenario 1: Alex is a 17-year-old gender-questioning person who uses they/them pronouns. Alex has been thinking a lot about hormone replacement therapy (HRT) but doesn’t know whom to ask for information or what options are available. Alex is also concerned about the cost of HRT, especially since they are currently experiencing homelessness and neither working nor in school.
As a caseworker, you should start by congratulating Alex on taking steps to learn more about themself; whatever decision they make around hormones means they’re more fully embracing their identity. As you begin to talk, be transparent with Alex about what information you may need to share outside of the conversation, as per mandated reporting requirements. Then ask Alex what kind of support they would like you to provide. Validate their desire to live fully as themselves by expressing their gender identity. Ask Alex what pronouns they use and use those pronouns consistently throughout your meeting. Ask them if there are other things—in addition to HRT—that would help them feel more affirmed in their gender (e.g., binders,24 packing,25 makeup, clothing, haircut) and support them in accessing these resources.
Next, talk with Alex about their options for care and how to pay for it. As a 17-year-old, Alex might be on a guardian’s insurance plan or on CHIP; if you can determine what plan they’re on, look up their insurance policies with them to see whether there are any requirements they need to meet before receiving HRT, and what the cost would be.26 You may search online with Alex for health care providers in the area who offer HRT, especially those who do so on a sliding scale. Keep an eye out for health care providers who share their pronouns, use gender-inclusive language on their website, and have space for patients to self-describe their gender, name, pronouns, and body parts on any intake forms. Also consider suggestions from colleagues or other young people who have experience with HRT. It may take some time to connect Alex with a provider, so discuss whether there is anything you can do in the meantime to support them.
Allow Alex to decide which health care provider to go to and remind them that they have the right to change providers at any time. Ask Alex if they would like you to be present during the first appointment to support Alex in self-advocacy and self-determination. Also ask Alex if they would like to connect with other young people going through similar experiences.
Finally, discuss the safety of HRT while experiencing homelessness. Alex will need safe and clean areas to apply hormone gel or inject their hormones, along with regular access to clean needles if injecting. They may also need to conceal their prescriptions from others on the street to minimize the threat of theft or discrimination, or to be mistaken as drug paraphernalia by police. Ask whether they have any additional safety concerns and come up with a plan to address these safety needs. Additionally, encourage Alex to discuss these concerns with their health care provider.
Next steps and ongoing care
Follow up with Alex about scheduling their first appointment with a health care provider and reiterate your willingness to be present to support them. After the first appointment, discuss Alex’s care plan with them and talk about how they will manage it. Ask them how they felt about the health care provider; if they don’t feel comfortable with the provider, help them find a new one or problem-solve as necessary to address their concerns. Follow up regularly with Alex about safety needs, concerns and provide support as needed. With Alex’s consent, connect them to peer support groups centered around their gender identity or other identities they hold, such as their race or ethnicity, their religion, or other identities they feel are their strengths.
Scenario 2: Bobby is an 18-year-old cisgender man who uses he/him pronouns. He is in his first relationship with a same-sex partner who is a few years older than him. In fact, this is his first-ever real relationship. His foster parents do not approve of his relationship. Bobby is curious about having sex and wants to be prepared for his first time.
As Bobby’s caseworker, you should start by validating that his curiosity in sex and relationships is natural. Encourage him to talk about his relationship, what he likes about his partner, how they met, and what he’s curious about. It’s important for Bobby to feel comfortable talking to you, so remember to actively listen. At the same time, be transparent about what information you’re able to keep confidential, and what information you may need to report to others.
Talk with Bobby about how he might approach his foster parents about their disapproval of his relationship. Determine whether Bobby feels physically and emotionally safe with his foster parents and develop a safety plan if he does not feel safe. If he does feel safe, discuss whether other family members could engage with the foster parents on Bobby’s behalf when challenges regarding this relationship arise. Brainstorm ways that Bobby can connect with his foster parents—for example, through a TV show or book, or via therapy. Ask whether Bobby would feel comfortable with you reaching out to his foster parents to provide them with resources or connect them to trainings on sexual identity. Be sure to confirm that these are reliable resources before sharing them with Bobby or his foster parents.
Become a trusted adult for Bobby by supporting him emotionally and providing useful information/advice. Encourage Bobby to reflect on whether he has a healthy relationship with his partner—one characterized by mutual respect for boundaries, clear and compassionate communication, and trust.27 Affirm Bobby’s right to take the relationship slowly or to set boundaries. Share information about safer sex practices, including regular STI testing,28 condoms,29 PrEP,30 and PEP.31 Connect Bobby with peers and organizations that will be supportive and understand his situation.
Next steps and ongoing care
Continue to discuss how Bobby feels with his foster parents and how they are treating his relationship. If Bobby does not feel physically or emotionally safe with his foster parents, follow the steps on the safety plan you made, which may include working to find him a new foster placement, if possible. Regularly ask Bobby about his intimate relationship and how he feels about his partner. Ensure that Bobby is receiving sexual health education and resources if he decides that he is ready to have sex. If Bobby is interested, connect him with supportive organizations and peers, particularly those who hold the same identities as him.
Scenario 3: Ash is a 15-year-old, transmasculine person who uses he/they pronouns and was recently placed in a short-term, all girls juvenile detention facility. He thinks he might be pregnant and is concerned about how staff will look at him and how uncomfortable it might be to go to a doctor for care.
As a caseworker, start your relationship with Ash by thanking them for being so open and honest about their experience. Ask Ash what pronouns they use and ask them their preference for how to use both pronouns—pick one and stick to it, pick one at different times, or use a mix. Ash says they want you to use both pronouns equally with them, but with medical providers, they’d prefer you to use just he/him pronouns. Confirm for Ash that this is a safe space for them to talk, but be transparent about what information can and cannot remain confidential. Acknowledge that the misalignment between Ash’s gender identity and their placement in the juvenile facility might be causing them a lot of discomfort or trauma and affirm that your priority is Ash’s safety. Ask whether they feel threatened by transphobic staff members or other youth. If they do, explore specific ways to ensure Ash’s safety in your facility, including moving Ash to a different unit or having conversations with other staff about inappropriate actions. However, be very careful to not put Ash at further risk: Moving them to solitary confinement can be damaging, and staff members may retaliate. Think intentionally and consciously about the moves you make to protect Ash.
Recognize that the idea of being pregnant may be causing gender dysphoria and other anxieties for Ash. Ask Ash how he would like to talk about the potential pregnancy. Are there non-gendered words or phrases he would like to use? Are there any words or phrases (e.g., vagina, period) he would like to avoid? Ash might also prefer to avoid other terms or phrases due to additional identities he holds; make space for him to share his boundaries. Listen to his preferences without judgement and do your best to use these phrases. If you forget to use the correct phrase, apologize, and move forward.
Let Ash know that it is standard procedure to receive a comprehensive health exam, including gynecological exams, within the first seven days of arriving at a juvenile facility. Find out what your facility’s pregnancy protocols are, and to what degree Medicaid exclusion policies might impact the type of care that is provided at the facility; explain these policies to the best of your ability. Explain some medical care options (e.g., pregnancy tests, prenatal care, abortion services when and where legal, and adoption counseling), what services are available on-site, and what services are only available if Ash is transferred to a medical facility. Also be transparent about where your knowledge is limited. Ask what medical care might interest Ash and note that a health care provider will need to describe options in more detail.
Medical procedures might be uncomfortable or traumatic for Ash as a transmasculine person—especially if he’s experienced any sexual violence or sex trafficking in the past—so be transparent about what the appointment with the health care provider might involve. Invite him to think about what procedures he might like to avoid, ways in which he would not like his body touched, and the pace at which he needs procedures to occur. Help him brainstorm ways to describe these boundaries and what questions he might want to ask so they have a clear sense of their medical options. Affirm his right to have agency over their health care. Talk through how the appointment might make Ash feel. Work with him to identify steps he can take to regulate his emotions during and after the appointment.
Next steps and ongoing care
Write out a care plan and ask Ash to identify some care goals for himself. With Ash’s assent, let them know you can pull together a care team; depending on the number of staff you have available, ask whether Ash prefers specific staff, such as those who have identities that align with his (such as race or religion). Ensure that these team members will use he/him pronouns as Ash has requested, respect Ash’s boundaries around medical procedures, and allow Ash to guide the care he receives.
Check in with Ash after the appointment to debrief, asking what went well and what could be changed for the next time. Reassure them that you’ll be a resource for as long as they’re in your facility. However, if they decide to go forward with the pregnancy, they likely won’t be in the detention facility throughout the entire pregnancy. Help them think through a plan for when he leave the facility and, if possible, create a list of recommended providers. Note that, depending on the state, Ash might need to reapply for Medicaid upon leaving; provide them with resources to support this application, or a referral to another case manager outside of the facility who can support. If Ash isn’t pregnant or chooses to not continue the pregnancy, you may want to discuss possible contraceptive methods that won’t cause or exacerbate gender dysphoria. Set a regular meeting time to continue following up with Ash for as long as they remain your client.
Scenario 4: Ty is a 10-year-old cisgender girl using she/her pronouns who is currently living in a group home. She has been very curious about her body but does not know whom to talk to. She recently got in trouble with one of the group home’s staff because she was caught watching porn on her school tablet. Staff checked her Google search history and found several graphic images and language about sex.
As a caseworker, start by establishing that you are a safe person with whom Ty can share her thoughts on sexuality in whatever way she feels comfortable. Tell her that there are no silly questions and that she doesn’t need to feel guilty or ashamed. Explain why you want to talk, what you’ll do with the information she provides, and why you might need to share that information with others. Have this conversation in a private, comfortable location that Ty identifies. Make it clear that you are there to support Ty in her journey to identify her sexual identity. Be intentional about the words and phrases you use, as language could very easily be interpreted as shaming.
Ask Ty clarifying questions about her behaviors and feelings. For example, what prompted her to start watching porn and how did it make her feel? Set boundaries around porn with Ty, explain why school tablets are not appropriate for watching porn, and discuss safe alternatives for exploring sexuality. Be aware of your facial expressions, body language, and tone, all of which can communicate shame to a young person.
Next steps and ongoing care
Emphasize to Ty that exploring one’s sexuality is healthy and natural. Define sexual orientation, talk through the ways in which people identify themselves, and allow Ty to begin defining her orientation for herself and at her own pace. Inquire about any sexual health education Ty is receiving either in school or at the group home. If none, find and refer Ty to community-based programs that provide age-appropriate sexual and reproductive health (SRH) programming. Additionally, define “consent” for Ty in an age-appropriate manner,32 discuss ways that she can seek consent, and identify expectations she should have of others who seek her consent around sexual contact. Continue to affirm that she is safe and that you are there to support her. Use a trauma-informed tool to screen for sexual trauma that might be contributing to Ty’s desire to look at porn, so that you can refer her to mental health care services as needed. Continue to check in with Ty about her experiences with sexuality, sexual orientation, and ongoing mental health care.
Incorporating trauma-responsive, LGBTQ+ affirming care into existing practices can help youth-supporting professionals address young people’s SRH needs. This approach ensures that young people who have experienced trauma are protected, respected, and cared for appropriately. It can be applied not only in the one-on-one interactions that providers have with youth, but also at an organizational level—for example, in considering how physical spaces for providing care are designed. Youth-supporting professionals can incorporate the principles of trauma-responsive, LGBTQ+ affirming care in their work by working to ensure young people’s physical and emotional safety, building authentic and consistent relationships, providing personalized care, and having a recognition and awareness of trauma.
The four scenarios provided in this resource illustrate how the principles of trauma-responsive, LGBTQ+ affirming care can be put into practice. While young people have individual needs, the principles can be used as a basic framework to promote SRH care and well-being. Caseworkers and case managers can, and should, use this resource to ensure that their practices are trauma-responsive and LGBTQ+ affirming.
For more information on key concepts regarding gender and sexual identity, and for additional resources for youth-serving professionals, please be sure to review the guiding document titled “Key Concepts to Guide Professionals Working with LGBTQ+ Youth.”
Suggested citation: Pliskin, E., Offiong, A., Tallant, J., & Kull, M. (2022). Using trauma-responsive, LGBTQ+ affirming care to connect young people to sexual and reproductive health services. Child Trends. https://activatecenter.org/resource/using-trauma-responsive-lgbtq-affirming-care-to-connect-young-people-to-sexual-and-reproductive-health-services/