Professional Psychology: Research and Practice © 2017 American Psychological Association

2018, Vol. 49, No. 1, 1– 8 0735-7028/18/$12.00 http://dx.doi.org/10.1037/pro0000154

An AFFIRMative Cognitive Behavioral Intervention for Transgender

Youth: Preliminary Effectiveness
Ashley Austin, Shelley L. Craig, and Sandra A. D’Souza
Barry University School of Social Work

Authentically expressing and navigating a transgender or gender nonconforming identity during adoles-
cence can be a difficult and painful process. Using a transgender affirmative approach to clinical practice,
psychologists and other mental health professionals can play a key role in supporting youth through this
process. To date, there is a paucity of research exploring the impact of transgender affirmative
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

interventions on well-being. The primary objective of this article is to present the results of a pilot study
This document is copyrighted by the American Psychological Association or one of its allied publishers.

exploring the preliminary effectiveness and acceptability of AFFIRM, an affirmative cognitive–

behavioral coping skills group intervention with transgender youth. This article will also describe
transgender-specific considerations for delivering transgender affirmative interventions. The transgender
subsample (N ⫽ 8) of participants in the study were between the ages of 16 and 18 and represented a
diversity of intersecting racial/ethnic, sexual, and gender identities. Results indicate that AFFIRM was
effective in significantly decreasing depression scores, and changes persisted through the 3-month
follow-up. While changes in coping were not statistically significant, scores trended in a positive
direction. Data indicate favorable responses to AFFIRM among transgender participants across a variety
of dimensions of satisfaction. While findings are preliminary, they are promising, addressing a critical
gap in intervention research aimed at decreasing depression and improving coping among transgender
youth. Future controlled studies are needed to explore the efficacy of AFFIRM with larger samples of
transgender youth.

Public Significance Statement

Our study examined the preliminary effectiveness of AFFIRM, an affirmative coping skills inter-
vention for transgender youth. Results indicate that transgender participants were highly satisfied
with the AFFIRM intervention and that it reduced their depression. Given the elevated risk of
depression, distress and suicide among transgender youth, the AFFIRM program holds promise for
improving well-being.

Keywords: affirmative, transgender, cognitive behavior therapy, outcomes

Over the last decade, mental and behavioral health researchers nonconforming youth populations. Transgender is an inclusive
and clinicians began to pay increasing attention to the mental term used to refer to individuals whose gender identity is not
health care needs and experiences of transgender and gender consistent with social and cultural gender expectations associated

This article was published Online First November 30, 2017. SANDRA A. D’SOUZA received her HBSc in human biology and health
ASHLEY AUSTIN received her MSW and PhD in Social Welfare from studies from the University of Toronto Scarborough. She is currently a
Florida International University. She is currently an Associate Professor at Master of Public Health Student at the Dalla Lana School of Public Health
Barry University School of Social Work and Distinguished Professor for at the University of Toronto, specializing in Social and Behavioural Health
the Center for Human Rights and Social Justice. Her research and clinical Sciences (Health Promotion). Her areas of professional interest include
practice interests revolve around advancing well-being among transgender public health policy, health equity, youth engagement, and social determi-
and gender diverse individuals, with particular emphasis on the develop- nants of health.
ment, testing and dissemination of affirmative practice approaches for the
THE AUTHORS WOULD LIKE TO THANK the transgender youth who partic-
transgender community.
ipated in AFFIRM and whose authenticity, courage, insight, and feedback
SHELLEY L. CRAIG received her PhD in Social Welfare from Florida
International University. She is currently the Associate Dean, Academic will continue to guide our work. We would also like to acknowledge the
and an Associate Professor at the Factor-Inwentash Faculty of Social Work efforts of the diligent and committed members of the AFFIRM research
at the University of Toronto and the Canada Research Chair in Sexual and and clinical team.
Gender Minority Youth (SGMY). Her areas of research and professional CORRESPONDENCE CONCERNING THIS ARTICLE should be addressed to
interest include sexual and gender minorities, cognitive– behavioral ther- Ashley Austin, Barry University School of Social Work, 11300
apy, information and communication technologies, clinical practice and NE 2nd Avenue, Miami Shores, FL 33161. E-mail: aaustin@barry
implementation science. .edu

1
 2 AUSTIN, CRAIG, AND D’SOUZA

with their assigned sex at birth. We use the term transgender knowledge and address experiences of minority stress associated with
broadly to encompass the spectrum of gender identities (e.g., pervasive interpersonal and structural transphobia.
agender, bigender, female to male [FTM], gender creative, gen-
derfluid, gender independent, gender nonconforming, gender neu- Countering Oppressive Mental Health Care:
tral, genderqueer male to female [MTF], third gender, transmas- Transgender Affirmative Practice
culine, two spirit). Although research with transgender youth
Transgender affirmative practice, a practice framework that honors
remains scarce, findings suggest that transgender youth have dis-
and values all experiences and expressions of gender (Austin & Craig,
tinct needs (Tishelman et al., 2015), as well as sources of resilience
2015a, 2015b), emerged in response to the pathologizing and stigma-
and coping (Austin, 2016; Singh, 2013). Moreover, beginning in
tizing approaches to mental behavioral health care for transgender
childhood transgender persons face marked social, cultural, and
persons. Transgender clients routinely experience discrimination, as
institutional barriers to well-being that are rooted in transphobia
well as a lack of competent and affirmative care in health and mental
(Goldblum et al., 2012; Grant et al., 2011). As a consequence, it is health settings (Grant et al., 2011; Stotzer, Silverschanz, & Wilson,
important that interventions targeting transgender youth address 2013). Particularly troubling are the harmful and unethical “repara-
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

the identity-based stressors and resultant health risks faced by tive” or “conversion” therapies aimed at changing sexual orientations
This document is copyrighted by the American Psychological Association or one of its allied publishers.

transgender youth as they navigate adolescence in contemporary and/or gender identity (Newman & Fantus, 2015). Accordingly, re-
society. The primary aim of this article is to present the results of cent U.S. national guidelines eschew these practices with transgender
a pilot study exploring the preliminary effectiveness and accept- youth (Substance Abuse and Mental Health Services Administration,
ability of AFFIRM, an affirmative cognitive– behavioral coping 2015). Transgender affirmative approaches that counter the negative
skills group intervention with a transgender subsample of youth. impact of transphobia by supporting and validating the identities,
Specifically, using a transgender-affirming approach to understanding strengths, and experiences of transgender individuals are increasingly
stress and resilience, AFFIRM aims to reduce depression and improve recognized as the gold standard in transgender care (Austin & Craig,
coping skills among transgender youth. 2015a; Burnes et al., 2010; Substance Abuse and Mental Health
Services Administration, 2015; Tishelman et al., 2015).
Transgender affirmative mental health care is of particular impor-
Identity-Based Stressors and Mental
tance for transgender youth who must grapple with the challenges of
Health Consequences adolescence and young adulthood while they simultaneously work to
Transgender young people experience disparate rates of psy- understand and assimilate a transgender identity in a cisgender dom-
chological distress, notably, depression, anxiety, and suicidality inated society, as well as struggle to change existing frameworks to be
(D’Augelli, Grossman, & Starks, 2006; Grossman & D’Augelli, more inclusive of the vast range of gender experiences (Austin, 2016;
2006, 2007; Ybarra, Mitchell, Kosciw, & Korchmaros, 2015). Singh, 2013; Tishelman et al., 2015). Interventions that affirmatively
Transgender youth have an exceptionally high risk of suicide attend to intersecting youth, gender, sexual, and cultural identities are
(Grant et al., 2011; Grossman & D’Augelli, 2007; Nuttbrock et necessary to adequately address the multifaceted experiences of trans-
al., 2010). Findings from the National Transgender Discrimi- gender youth.
nation Survey (NTDS) indicate that 45% of young adults (18 –
24) reporting attempted suicide (Haas, Rodgers, & Herman, AFFIRM
2014). Mental health risks among transgender young people AFFIRM is an affirmative cognitive– behavioral coping skills
have been empirically linked with hostile school climates, in- group intervention targeting youth with sexual and/or gender mi-
terpersonal harassment, bullying, and victimization (D’Augelli, nority identities. AFFIRM was developed through community-
Pilkington, & Hershberger, 2002; D’Augelli, et al., 2006; Gold- based research efforts (see Austin & Craig, 2015b, for a full review
blum et al., 2012; Toomey, Ryan Diaz, Card, & Russell, 2010; of the intervention development process). Using youth and pro-
Ybarra et al., 2015), as well as structural transphobia (e.g., vider feedback, AFFIRM was developed and adapted to ensure (a)
bathroom laws; Perez-Brumer, Hatzenbuehler, Oldenburg, & an affirming stance toward sexual and gender diversity, (b) rec-
Bockting, 2015; Seelman, 2016). ognition and awareness of sexual and gender identity specific
An accurate and nuanced understanding of the mental and behav- sources of stress (e.g., transphobia, homophobia, cissexism, het-
ioral health risks among transgender youth is facilitated by the mi- erosexism), (c) a youth-centric orientation that recognizes and
nority stress model (Meyer, 2003, 2015). The minority stress model attends to the unique experiences of navigating sexual and gender
was developed to explain increased risk for negative health outcomes minority identities during adolescence/young adulthood, and (d)
and maladaptive behaviors among individuals with sexual and gender the delivery of cognitive– behavioral therapy (CBT) content within
minority identities. According to minority stress theory, members of an affirming framework that attends to the intersectionality of
sexual and gender minority groups experience chronic stress associ- identity-based experiences. Given the distressing experiences often
ated with identity-based stigma and prejudicial encounters, which in precipitated by minority stress among sexual and gender minority
turn contributes to a higher prevalence of mental health and behav- youth, a critical component of AFFIRM is that it is grounded in an
ioral issues (Meyer, 2003). Accumulating empirical research supports understanding of the pervasiveness and consequences of identity-
the minority stress model for transgender individuals (Bockting, based stigma and prejudice. AFFIRM is aimed at promoting pos-
Miner, Swinburne Romine, Hamilton, & Coleman, 2013; Grant et al., itive change and healthy coping through the creation of a safe,
2011; Hendricks & Testa, 2012; Marcellin, Scheim, Bauer, & Red- affirming, and collaborative therapeutic experience.
man, 2013). As a consequence, interventions aimed at addressing AFFIRM was developed with the recognition that sexual and
mental and behavioral health among transgender youth must ac- gender minority youth may develop patterns of negative thinking
 AFFIRMATIVE INTERVENTION FOR TRANSGENDER YOUTH 3

about themselves as a result of early and persistent exposure to data was collected at 3 months’ postintervention. Previous research
transphobic and homophobic attitudes, beliefs, and behaviors, suggests that interventions delivered in a retreat format are accept-
(Bockting et al., 2013; Mizock & Mueser, 2014). Negative emo- able for pilot studies and may be particularly useful when imple-
tional and behavioral responses (e.g., feelings of hopelessness, menting interventions with difficult to reach populations, because
suicidality, distress) often result from the internalization of nega- of efficient content delivery (Davey, 2004; Wilton et al., 2009). In
tive or stigmatizing thoughts about one’s minority identity addition, the weekend retreat format may contribute the additional
(Breslow et al., 2015; Mizock & Mueser, 2014). Using CBT benefit of creating a sense of belonging and connectedness (Arn-
strategies, AFFIRM actively targets identity-based stressors (e.g., aert, Gabos, Ballenas, & Rutledge, 2010), factors that may impact
homophobic and transphobic bullying, family rejection) that con- intervention acceptability, engagement, and retention.
tribute to emotional distress among transgender young people.
Within an affirming therapeutic context, AFFIRM engages sexual
Recruitment
and gender minority youth in CBT strategies aimed at improving
coping related to both internal and external sources of distress. Participants for the full study were recruited using venue-based
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

While AFFIRM has a key aim of validating and affirming all and purposive sampling through community-based organizations
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sexual orientations and gender identities, it is primarily a cognitive– and online sources. The research team used e-mail, posters in
behavioral coping skills intervention aimed at improving coping and relevant youth serving agencies or spaces, texting, a closed Face-
reducing emotional distress. Rooted in the tenets of CBT (Beck, 1970, book group, and a Twitter account to recruit participants. Inter-
2011), AFFIRM aims to improve emotional and behavioral function- ested youth were individually screened for eligibility during a
ing by targeting underlying, problematic cognitions. It is well estab- short telephone or text interview. Inclusion criteria for AFFIRM
lished that CBT is an efficacious treatment for major mental health were as follows: (a) youth were aged 14 –18 years (upon enroll-
concerns (e.g., depression, anxiety, traumatic stress) faced by children ment) that identify as nonheterosexual and/or noncisgender; (b)
and youth (Albano & Kendall, 2002; Cary & McMillen, 2012; Klein, youth were able to converse in English; and (c) youth agreed to
Jacobs, & Reinecke, 2007); mental health concerns that are vastly participate in a 2-day retreat. The study was described in detail to
overrepresented among transgender young people (D’Augelli, et al., eligible youth and informed consent, parental consent, or when
2006; Grossman & D’Augelli, 2006, 2007; Haas et al., 2014; Ybarra necessary, youth assent was obtained. Participants received com-
et al., 2015). AFFIRM represents an adapted version of CBT that pensation for participating in AFFIRM. Meals, snacks, and trans-
specifically targets the unique needs of transgender young people. portation tokens were also provided during the weekend retreat.
AFFIRM is designed to be delivered in a flexible manner to All recruitment procedures were approved by the Research Ethics
meet the diverse needs of sexual and gender minority youth in a Board at a major Canadian university.
variety of practice settings (e.g., schools, communities, mental
health agencies, hospitals). The primary aim of this article is to
Participants
describe the experiences and outcomes of a transgender subgroup
of youth (N ⫽ 8) who participated in an eight-module pilot study The transgender subsample (N ⫽ 8) of participants in the
of AFFIRM (total N ⫽ 30). The results of the full study are AFFIRM pilot intervention were between the ages of 16 and 18
reported elsewhere (Craig & Austin, 2016) as are detailed discus- and represented a diversity of intersecting racial/ethnic, gender,
sions of our transgender affirmative approach to CBT (Austin & and sexual identities. Data for all participants was collected across
Craig, 2015a; Austin, Craig & Alessi, in press). Given the paucity the following demographic categories: age, race/ethnicity, gender
of mental health intervention research conducted with transgender identity, sexual orientation, and level of gender identity “outness”
youth, as well as some research suggesting that groups serving (Table 1). Response options for demographic categories were not
sexual and gender minority youth together (e.g., Gay Straight mutually exclusive. Participants reported a variety of gender iden-
Alliances [GSAs], support groups) may not equally benefit trans- tities, with most selecting at least two categories: nonbinary (6),
gender youth (Greytak, Kosciw, & Boesen, 2013), it is important to male (2), female (2), transgender (2), two-spirit (1), gender inde-
focus on the preliminary effectiveness of AFFIRM for the subsample pendent (1), and other–“figuring things out” (1). Participants’
of transgender-identified participants. This study reports preliminary identified sexual orientation as follows: queer (5), pansexual (2),
findings regarding the effectiveness of AFFIRM in reducing depres- questioning (2), and asexual (1). A majority of participants re-
sion and enhancing coping skills among transgender youth. More- ported being “out” to many people in their lives, and none of the
over, satisfaction data associated with acceptability of AFFIRM’s participants identified as “not out.”
content, context, and format will be explored.
Intervention Procedures
Method
All consenting/assenting participants took the AFFIRM prein-
Design tervention assessment no more than 4 weeks before attending the
weekend intervention retreat. The AFFIRM weekend retreat was
A pilot study using a one-group design was used to explore held at a community center serving the local sexual and gender
feasibility, preliminary outcomes, and satisfaction with AFFIRM. minority community. The 8-module AFFIRM intervention was
AFFIRM was implemented using an eight-module, weekend group delivered in a group format wherein each of three groups consisted
retreat format in a major urban city in Canada during the summer of 10 youth and two cofacilitators. Groups were conducted con-
of 2014. In addition to postintervention data collected immediately currently in separate meeting spaces at the community center.
following the conclusion of the weekend group retreat, follow-up AFFIRM was delivered by three pairs of facilitators, each with a
 4 AUSTIN, CRAIG, AND D’SOUZA

Table 1 feelings, (6) Planning to overcome counterproductive thoughts and

Demographic Characteristics negative feelings, (7) Understanding the impact of minority stress
and homo/transphobia on social relationships, (8) Developing safe,
Variable n supportive, and identity affirming social networks.
Age
16 1
17 1
Transgender-Specific Considerations
18 6 AFFIRM protocols, written materials, and experiential activities
Gender identity
Nobinary 6 were intentionally developed to be inclusive of and responsive to
Queer 5 the unique experiences of transgender youth. The first iteration of
Female 2 the AFFIRM manual was developed in partnership with a
Transgender 2 transgender-identified MSW intern with years of expertise devel-
Male 1
oping identity affirming and inclusive interpersonal violence train-
Two-spirit 1
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Gender independent 1 ing materials (Quinn, Santiago, Nichols, & Leventhal, 2011).
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Other–figuring things out 1 Throughout the AFFIRM development process, feedback from
Sexual orientation transgender-identified mental health care providers, community
Queer 5 members, and youth informed adaptations to the manual and
Pansexual 2
Questioning 2 revisions to activities, exercises, and examples. For instance, when
Asexual 1 exploring minority stress in the first and second sessions, AFFIRM
Race/ethnicity explicitly addresses the impact of transphobia and cisgenderism, in
White (Canadian, European) 5 addition to homophobia and heterosexism. Using real world ex-
Mixed background 2
amples to illustrate CBT strategies is critical to the delivery of
Asian 1
Black (African, Canadian, Caribbean) 1 AFFIRM. As such, great care was taken to develop examples that
Indigenous, First Nations, Inuit, Metis 1 were relevant to the unique experiences of transgender youth. For
Latin American 1 example, in an activity called “Talking to Your Thoughts,” par-
Out Status—Is “out” to ticipants were taught to challenge negative thinking and internal-
Teachers, doctors, or other adults 7
Many people at school 6 ized transphobia and homophobia using a classic CBT technique,
Online friends 6 the A-B-C-D method (Ellis, 1991). To facilitate understanding of
At least one friend 5 the approach and its application to their own lives, participants
At least one parent/caregiver 4 were provided with sample scenarios which include some
Siblings 4
transgender-specific experiences (Figure 1).
2⫹ parents 2
Extended family 2 Consideration was given to create a transgender-affirming context
Other 1 to support the delivery of AFFIRM. AFFIRM was implemented at a
Is not “out” 0 community center that had gender-neutral restrooms and was visibly
welcoming to transgender people (e.g., posters of transgender-
inclusive events, transgender staff). In addition, AFFIRM welcome
minimum of 1 year of experience working with youth with sexual procedures began with project directors and facilitators introducing
and gender minority identities, and with some history of using themselves using their preferred names and personal pronouns as a
CBT-based interventions. All facilitators participated in a 5-hr train- way to support transgender youth and model transgender inclusivity
ing focused on the affirmative framework, AFFIRM study protocols, (inclusive name tags that listed name and preferred pronouns were
and the eight-modules of the manualized AFFIRM intervention in the also utilized).
month preceding the intervention retreat. In response to research
suggesting that transgender experiences are often absent or inade-
Measures
quately addressed in groups targeting sexual and gender minority
youth together (Greytak et al., 2013), facilitator training emphasized To identify the impact of AFFIRM on transgender youth well-
the importance of creating contexts which were implicitly and explic- being, outcome measures of depression and reflective coping were
itly inclusive of, and attendant to, the experiences of transgender collected during the preintervention assessment, postintervention
participants. assessment, and at the 3-month follow-up assessment. In addition,
The AFFIRM intervention focuses on facilitating coping skills AFFIRM satisfaction data was collected at postintervention and at
and behaviors to support healthy development and counteract the the 3-month follow-up.
negative effects of minority stress. Through a combination of The Beck Depression Inventory (BDI-II). Depression was
psychoeducation, interactive learning, group rehearsal, and peer assessed with the 21-item version, the BDI-II (Beck, Steer, &
support and feedback, each module was aimed at developing Brown, 1996), which has been widely used to measure depression
specific skills among participants. The eight- modules of AFFIRM and related cognitions of adolescents, including sexual and gender
correspond with the following content areas: (1) Introduction to minority populations (Heck, Flentje, & Cochran, 2011). The
CBT and understanding minority stress, (2) Understanding the BDI-II includes dimensions such as pessimism and self-dislike
impact of homophobic and transphobic attitudes and behaviors on which are scored on a scale from 0 to 3. For example, 0 ⫽ “I am
stress, (3) Understanding how thoughts affect feelings, (4) Using not discouraged about my future” to 3 ⫽ “I feel my future is
thoughts to change feelings, (5) Exploring how activities affect hopeless and will only get worse.” Higher total scores indicate
 AFFIRMATIVE INTERVENTION FOR TRANSGENDER YOUTH 5

Challenging negative thinking and internalized transphobia through the ABCD method

A: is the Activating event; what happened.

B: is the Belief or the thought that you are having; that is, what you tell yourself
about what is happening.
C: is the Consequence of your thought; that is, the feeling you have as a result of
your thought.
D: is the way in which you Dispute or talk back to your thought.

Example 1
A: I am genderqueer.
B: “No one can be happy if they are genderqueer,” or “Being genderqueer is going
to ruin my life,” and “I won’t be able to handle the discrimination and stigma
associated with being genderqueer.”
C: I feel hopeless and worried
D: "There are people who are genderqueer who are as happy as people with other
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identities." "Discrimination against genderqueer people happens and it is

This document is copyrighted by the American Psychological Association or one of its allied publishers.

awful, but it won’t ruin each minute of my life.” “I am a strong and determined
person, who can have a good life in spite of discrimination.” “Instead of
wasting energy doubting myself and feeling anxiety, I can use my energy to
figure out the best way to live an authentic life.”

Example 2
A: My father told me that I am going to hell because I am transgender.
B: “My father hates me and wishes I wasn’t born.” “Maybe I am going to hell for
being transgender.” “There is something wrong with me.”
C: I feel sad, scared, and angry.
D: “I am not going to hell and there is nothing wrong with me.” “There are many
religions and religious viewpoints that honor, validate, and embrace
transgender people and identities.” “Transgender people are as worthy and
valuable as people with all other gender identities.” “My father is angry and
confused about me being transgender because he doesn’t understand. He may
need some time and help to figure things out.”

Figure 1. Talking to your thoughts.

more severe depression with the standardized values (0 –13 mini- Data Analyses
mal depression, 14 –19 mild depression, 20 –28 moderate depres-
Paired-sample t tests were conducted to measure the immediate
sion, 29 – 63 severe depression). The BDI-II has high test–retest
(short-term) postintervention change (T1-T2; n ⫽ 8) and the
reliability (r ⫽ .93) and has high internal consistency (␣ ⫽ .91;
3-month postintervention (long-term) change (T1-T3 and T2-T3;
Beck, Steer, Ball, & Ranieri, 1996).
n ⫽ 6) in the outcomes of depression and reflective coping in the
Reflective Coping Subscale (RCS). Coping was assessed
AFFIRM transgender participants.
using the 11-item reflective coping subsection of the Adolescent
Proactive Coping Inventory (PCI-A; ␣ ⫽ .67–.88; Greenglass,
Schwarzer, & Laghi, 2008). The RCS taps into participant’s cog- Results
nitive and behavioral coping through questions such as “I address
a problem from various angles until I find the appropriate action.” Depression
Response options range from 1 (almost never) to 5 (almost al-
Findings indicated that AFFIRM elicited a statistically signifi-
ways), and higher total scores indicate greater reflective coping
cant reduction in the depression scores both immediately T1 (M ⫽
skills.
37.50, SD ⫽ 12.29) to T2 (M ⫽ 28.25, SD ⫽ 10.24); t(7) ⫽ 5.167,
AFFIRM Satisfaction Survey. A 17-item questionnaire,
p ⫽ .001 and at 3 months’ postintervention T1 (M ⫽ 40.67, SD ⫽
adapted from previously research with sexual and gender minority
12.21) to T3 (M ⫽ 29.33, SD ⫽ 6.77); t(5) ⫽ 3.442, p ⫽ .018
youth (Craig, Austin, & McInroy, 2014), assessed acceptability,
compared with baseline. Depression scores also reduced nonsig-
perceived utility, and overall satisfaction associated with the nificantly between T2 (M ⫽ 32.17, SD ⫽ 7.49) and T3 (M ⫽
AFFIRM intervention. The satisfaction survey included statements 29.33, SD ⫽ 6.77); t(5) ⫽ 1.224, p ⫽ .276. While results indicate
such as, “I would recommend this program to a sexual/gender notable reductions in depression, mean scores at T2 and T3 remain
minority friend” and “I will use what I learned to help with my in the BDI-II Severe range (29 – 63).
problems.” Items were rated from 1 (not true) to 4 (very true), and
a total score was calculated. The following open-ended qualitative
Coping
questions were also included: “What suggested changes do you
have for the AFFIRM program?” and “What were some of things There were no significant differences between T1 (M ⫽ 30.17,
you liked most about the AFFIRM program.” SD ⫽ 5.78) and T2 (M ⫽ 30.83, SD ⫽ 5.34); t(5) ⫽ ⫺0.287, p ⫽
 6 AUSTIN, CRAIG, AND D’SOUZA

.786 or T2 (M ⫽ 30.83, SD ⫽ 5.34) and T3 (M ⫽ 31.00, SD ⫽ tion and at the 3-month follow-up, differences were not statisti-
8.25); t(5) ⫽ ⫺0.062, p ⫽ .953 reflective coping scores. cally significant. It is possible that the very small sample size
precluded the data from achieving significance. Furthermore, the
concentrated delivery of the intervention may not have enabled
Satisfaction
participants enough time to practice the skills necessary to see
All eight transgender participants who completed the preinter- significant changes in reflective coping. Nevertheless, our significant
vention assessment also attended and completed the AFFIRM findings for depression are encouraging, given that AFFIRM’s ap-
intervention and the postintervention assessment. A total of six proach to decreasing depression and other forms of psychological
transgender participants completed the 3-month follow-up. There distress is through the use of more effective coping strategies. More-
were no apparent differences between the six transgender partici- over, satisfaction data (both qualitative and numerical data) indicate
pants who were retained at T3 and the two who were not. Reten- that participants found AFFIRM’s emphasis on coping skills training
tion rates for the transgender subsample (75%) were notably particularly helpful. Early findings point to the importance of explor-
higher than retention rates for the full sample (56%), suggesting a ing the effectiveness of AFFIRM in larger studies which will eluci-
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

high level of engagement. Overall total scores (range ⫽ 17– 68) on date the intervention’s impact on coping and depression outcomes, as
This document is copyrighted by the American Psychological Association or one of its allied publishers.

the AFFIRM satisfaction questionnaire at posttest (M ⫽ 50.60, well as any possible indirect relationships between coping and de-
SD ⫽ 9.48) and at the 3-month follow-up (M ⫽ 52.60, SD ⫽ 6.58) pression among participants.
suggest high levels of satisfaction among the transgender sub- Overall, data indicate a positive response to AFFIRM among
sample of youth. Notably, seven out of eight transgender partici- transgender participants across a variety of dimensions. Notably,
pants strongly agreed or agreed that they “would recommend all eight transgender participants recruited into the study attended
AFFIRM to other youth with sexual and/or gender minority iden- the first session and were retained in the program through postas-
tities” and that they “can use what they learned to deal with their sessment. In addition, retention rates at follow-up were much
stress and solve some of their problems.” All but one transgender higher among the transgender subsample (75%) than the full
participant reported that “the topics and content addressed in sample of participants (56%). These findings along with satisfac-
AFFIRM were relevant to my life.” Finally, all (n ⫽ 8) transgender tion scores and qualitative responses (e.g., accessibility, positivity,
participants strongly agreed or agreed that “the AFFIRM staff and safe to share) suggest that transgender youth were comfortable, as
group facilitators were supportive and helpful.” well as engaged and invested in the intervention. Noteworthy is the
Qualitative responses suggest that AFFIRM was successful in finding that seven of the eight transgender participants identified
supporting transgender youth identity, as well as promoting posi- that AFFIRM was “relevant” to their own lives. Given research
tive coping and problem solving. When asked which aspects of indicating that services provided to sexual and gender minority
AFFIRM were most helpful, transgender participants cited the youth together often insufficiently attend to the needs and experi-
importance of “being able to speak openly” and “talk about gender ences of transgender youth, we think these findings are notewor-
issues”, in a context that was full of “positivity” and “accessible to thy.
youth.” Other responses suggest that some transgender youth were This pilot study of AFFIRM had multiple limitations. The lack
particularly pleased with the CBT components of AFFIRM includ- of a control or comparison condition makes it impossible to
ing “the coping skills taught to us.” Suggestions for improvement determine whether changes in depression were the result of par-
among transgender participants included greater attention to “in- ticipation in AFFIRM or other uncontrolled variables. Although
tersectionality” and “issues facing transgender people of color,” as decreases in depression persisted to the 3-month follow-up, be-
well as, adding “more time” to AFFIRM. Overall, transgender cause there were no additional follow-up periods it unknown whether
youth responded well to the AFFIRM approach and format as the results lasted longer. Most importantly, findings should be inter-
evidenced by the positive satisfaction scores, the 100% atten- preted with caution because of the very small number of transgender
dance and completion rates, and the satisfactory retention rates youth in the study. The small sample size may have impacted our
at follow-up. power to detect meaningful differences between scores associated
with pre-, post-, and follow-up assessments. Although the retention
rate for the follow-up assessment for transgender participants was
Discussion
relatively high (75%), because of the small beginning sample size, the
Preliminary findings from AFFIRM suggest the potential effec- attrition of any study participants represents a further limitation.
tiveness of our affirmative CBT approach for reducing depression There are several directions for future research to build upon
among transgender youth. These findings are particularly compel- findings from this open trial pilot study. An important next step to
ling given that transgender youth suffer disproportionately high assess efficacy of AFFIRM is to conduct a randomized control
rates of depression and suicidality (Grossman & D’Augelli, 2007), study using a larger sample of transgender youth. Subsequent
mental health problems that do not necessarily abate in adulthood studies of AFFIRM must focus on increasing the number of
as indicated by a growing body of literature illustrating disparate transgender participants by oversampling transgender youth. To
rates of depression among transgender adults (Budge, Adelson, & develop a more nuanced understanding of the applicability and
Howard, 2013; Nemoto, Bödeker, & Iwamoto, 2011; Nuttbrock et effectiveness of AFFIRM, it is important that future studies in-
al., 2010). Moreover, to date there are no known empirically tested clude a broad range of transgender youth with a spectrum of
interventions targeting risk factors specific to transgender youth (binary and nonbinary) identities, as well as youth with varying
(e.g., transphobic stigma, discrimination, and victimization). pretreatment levels of adjustment (i.e., youth with more severe
Although reflective coping scores among the transgender sub- symptomology, as well as those with mild and moderate symp-
sample changed in a positive direction from pre- to postinterven- toms). While this study examined the delivery of AFFIRM in a
 AFFIRMATIVE INTERVENTION FOR TRANSGENDER YOUTH 7

2-day format with primary aims of establishing acceptability, sional Psychology: Research and Practice, 46, 21–29. http://dx.doi.org/
feasibility and initial effectiveness, it is important that future 10.1037/a0038642
studies explore the delivery of AFFIRM in a variety of formats that Austin, A., & Craig, S. L. (2015b). Empirically supported interventions for
may be beneficial for transgender youth. Specifically, two areas of sexual and gender minority youth. Journal of Evidence-Informed Social
expansion include an exploration of the effectiveness of delivering Work, 12, 567–578. http://dx.doi.org/10.1080/15433714.2014.884958
AFFIRM in a weekly community-based format which may en- Austin, A., Craig, S. L., & Alessi, E. A. (in press). Transgender affirmative
cognitive behavior therapy. The Psychiatric Clinics of North America.
hance opportunities to practice and rehearse of new skills between
Beck, A. (1970). Cognitive therapy: Nature and relation to behavior ther-
each session, as well as delivering AFFIRM in an individual,
apy. Behavior Therapy, 1, 184 –200. http://dx.doi.org/10.1016/S0005-
online format which may increase accessibility and retention for 7894(70)80030-2
trans youth (Craig, McInroy, McCready, & Alaggia, 2015). Beck, A. T., Steer, R. A., Ball, R., & Ranieri, W. (1996). Comparison of
Beck Depression Inventories-IA and-II in psychiatric outpatients. Jour-
nal of Personality Assessment, 67, 588 –597. http://dx.doi.org/10.1207/
Conclusions
s15327752jpa6703_13
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

Findings from the current study are promising, addressing a Beck, A. T., Steer, R. A., & Brown, G. K. (1996). Beck depression
This document is copyrighted by the American Psychological Association or one of its allied publishers.

critical gap in intervention research with transgender youth. Our inventory manual. San Antonio, TX: Psychological Corporation.
study findings are especially encouraging given the relative ab- Beck, J. S. (2011). Cognitive behavior therapy: Basics and beyond. New
sence of empirically based interventions that target the specific York, NY: Guilford Press.
needs of transgender young people, as well as challenges associ- Bockting, W. O., Miner, M. H., Swinburne Romine, R. E., Hamilton, A.,
ated with some programs to adequately serve transgender youth & Coleman, E. (2013). Stigma, mental health, and resilience in an online
sample of the U.S. transgender population. American Journal of Public
(Greytak et al., 2013). AFFIRM is an innovative and inclusive
Health, 103, 943–951. http://dx.doi.org/10.2105/AJPH.2013.301241
approach to practice with sexual and gender minority youth.
Breslow, A. S., Brewster, M. E., Velez, B. L., Wong, S., Geiger, E., &
Within AFFIRM the needs and experiences of transgender youth Soderstrom, B. (2015). Resilience and collective action: Exploring buf-
are wholly integrated into the clinical model, as well as into the fers against minority stress for transgender individuals. Psychology of
practice context. While AFFIRM engages youth through its affir- Sexual Orientation and Gender Diversity, 2, 253–265. http://dx.doi.org/
mative framework (Austin & Craig, 2015a), which acknowledges, 10.1037/sgd0000117
validates, and supports youth across a spectrum of intersecting Budge, S. L., Adelson, J. L., & Howard, K. A. (2013). Anxiety and
sexual, gender, and cultural identities, youth feedback suggests depression in transgender individuals: The roles of transition status, loss,
that even greater attention to the intersectionality of minority social support, and coping. Journal of Consulting and Clinical Psychol-
identities will be an important focus during future implementation ogy, 81, 545–557. http://dx.doi.org/10.1037/a0031774
studies of AFFIRM. Moreover, AFFIRM offers empirically sup- Burnes, T. R., Singh, A. A., Harper, A. J., Harper, B., Maxon-Kann, W.,
ported strategies for decreasing depression and enhancing coping Pickering, D. L., & Hosea, J. (2010). American Counseling Association:
skills to deal with identity-based stressors, as well as, to manage Competencies for counseling with transgender clients. Journal of LGBT
stressors associated with navigating the path from adolescence to Issues in Counseling, 4, 135–159.
Cary, C. E., & McMillen, J. C. (2012). The data behind the dissemination:
adulthood. Because AFFIRM was developed to be implemented
A systematic review of trauma-focused cognitive behavioral therapy for
flexibly, it can be delivered using either a group or individual
use with children and youth. Children and Youth Services Review, 34,
format, and across a variety of settings to meet a wide array of
748 –757. http://dx.doi.org/10.1016/j.childyouth.2012.01.003
client and service delivery needs, an important component of Craig, S. L., & Austin, A. (2016). The AFFIRM open pilot feasibility
interventions targeting invisible and marginalized subgroups, such study: A brief affirmative cognitive behavioral coping skills group
as transgender youth. Finally, our findings suggest that when intervention for sexual and gender minority youth. Children and Youth
rooted from the beginning in a transgender affirming and inclusive Services Review, 64, 136 –144. http://dx.doi.org/10.1016/j.childyouth
framework, interventions delivered to sexual and gender minority .2016.02.022
youth together, can be similarly accessible and effective for trans- Craig, S. L., Austin, A., & McInroy, L. (2014). School-based groups to
gender participants. support multiethnic sexual minority youth resiliency: Preliminary effec-
tiveness. Child & Adolescent Social Work, 30, 87–106. http://dx.doi.org/
10.1007/s10560-013-0311-7
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