UNIT 6: 
SEXUAL ORIENTATION AND GENDER IDENTITY AND EXPRESSION
INTRODUCTION:
For many service providers, few subjects can feel more difficult, confusing, or complicated than sexual orientation and gender identity and expression. Things like gender identity and sexual orientation, which feel basic to many people, are built into our assumptions through our language, through the way we learn, through the ways we are taught to interact with each other and our communities. Sometimes, our personal, cultural, or religious values and experiences put us into conflict with our desire to help clients who may have sexual or gender identities that feel foreign Ð even wrong Ð to us. 
As providers and counselors, we must understand that there are a range of sexual orientations and identities and gender identities and expressions. Adolescence is a time of learning, when young people begin to define an individual identity, explore gender and sexuality and analyze how these pieces fit together.  An adolescent client who is struggling with their sexual orientation or gender identity often faces not only internal conflict and confusion, but also extreme stigma, discrimination, pressure, and even violence from their society, their peers, and their families. When sexual orientation and gender identity intersect with other discrimination factors such as disability, ethnicity and race, the risk for adolescents to experience, stigma, pressure and violence is even higher. It is the responsibility of providers to provide accurate, accessible and unbiased information and services to all adolescent clients, even if their sexual orientation, gender identity or gender expression conflicts with their personal values and opinions. 
     	UNIT TRAINING OBJECTIVE:
To help providers support all adolescent clients of different sexual orientations and gender identities and expressions with inclusive services and non-judgmental counseling.
     	SPECIFIC LEARNING OBJECTIVES:
By the end of the unit, participants will be able to:
1. Define concepts related to sexuality, sexual orientation, gender, gender identity, and gender expression. 
2. Describe challenges, pressures, and risks for adolescents based on their sexual orientation and gender identity and expression and how these can multiply when it comes to adolescents with disabilities. 
3. Identify specific service and counseling needs for transgender and intersex adolescents. 
4. Model inclusive counseling techniques for all adolescents regardless of sexual orientation or gender identity or expression. 
     	TOTAL TIME:  3 hours 45 minutes

UNIT OVERVIEW: 
Session
Methods
Materials
Time
6.1
Group work
Flipcharts and markers
Term and definition cards
Tape
30 minutes
6.2 
Group discussion
Trainer presentation
Slides 6.1-6.13
Participant Handout 6a
1 hour
1. 6.3
Values clarification
Trainer presentation
Flipcharts and markers
Slides 6.14-6.21
1 hour 15 minutes
6.4
Fishbowl role play
TrainerÕs Tool 6b
45 minutes
Unit Summary
Ice-breaker

15 minutes

     	WORK FOR TRAINERS TO DO IN ADVANCE:

* Review slides 6.1-6.21
* Research legal and clinical policy on rights of LGBTQI clients in your area
* Find a local organization that works with LGBTQI young people and with LGBTQI adolescents with disabilities if possible, as a resource for participants. If that is not possible, find a local Organization of Persons with Disabilities (OPD) that works on disability, gender, and sexuality as an additional resource.
* SO 6.1: Prepare term and definition cards for group exercise. Review terms and definitions and research any unfamiliar information. 
* SO 6.4: Prepare TrainerÕs Tool 6b: Client descriptions.


     	MAJOR REFERENCES AND TRAINING MATERIALS:

Advocates for Youth. 2016. Lesbian, Gay, Bisexual, and Transgender (LGBT) Youth in the Global South. Washington, DC: Advocates for Youth. 
Amnesty International. 2015. Respect My Rights, Respect My Dignity: Module 3 Ð Sexual and Reproductive Rights are Human Rights. London: Amnesty International. 
Callen Lorde Community Health Center. 2016. Protocols for the Provision of Hormone Therapy. New York: Callen Lorde CHC. http://callen-lorde.org/graphics/2016/06/Callen-Lorde-TGNC-Hormone-Therapy-Protocols.pdf
Frader, J., P. Alderson, A. Asch, C. Aspinall, D. Davis, A. Dreger, J. Edwards, E. Feder, A. Frank, L. Abelow Hedley, E. Kittay, J. Marsh, P. S. Miller, W. Mouradian, H. Nelson, and E. Parens. 2004. Health Care Professionals and Intersex Conditions. http://www.isna.org/pdf/Frader2004.pdf. 
Goblet, D. 2011. Handicap et homosexualitŽ: double tabou, double discrimination? Namur: UniversitŽ Notre-Dame de la Paix. http://yagg.com/files/2011/08/TFE-HANDICAP-ET-HOMOSEXUALITEDOUBLE-TABOU-DOUBLE-DISCRIMINATION.pdf 
Institute of Medicine (US) Committee on Lesbian, Gay, Bisexual, and Transgender Health Issues and Research Gaps and Opportunities. 2011. The Health of Lesbian, Gay, Bisexual, and Transgender People: Building a Foundation for Better Understanding. Washington (DC): National Academies Press (US).ÊAvailable from: https://www.ncbi.nlm.nih.gov/books/NBK64808/
Intersex Society of North America. 2006. Clinical Guidelines for the Management of Disorders of Sex Development in Childhood. Rohnert Park, CA: ISNA. 
 Leonard, W. & Mann, R. 2018.  The everyday experiences of lesbian, gay, bisexual, transgender and intersex (LGBTI) people living with disability. La Trobe University. 
Msekele, S. 2018. ÒBeing Disabled, Black and Queer in South Africa: A Personal Journey.Ó  P. Chappell and M. De Beer (eds.), Diverse Voices in Disabled Sexualities in the Global South. New York: Palgrave Macmillan; 127-130.
Pan American Health Organization [PAHO], John Snow, Inc., World Professional Association for Transgender Health, et al. 2014. Blueprint for the Provision of Comprehensive Care for Trans Persons and Their Communities in the Caribbean and Other Anglophone Countries. Arlington, VA: John Snow, Inc.
Society for Adolescent Health and Medicine. 2013. Recommendations for Promoting the Health and Well-Being of Lesbian, Gay, Bisexual and Transgender Adolescents: A Position Paper of the Society for Adolescent Health and Medicine. Journal of Adolescent Health (52) pp. 506-510. 
World Health Organization. 2015. Technical Brief: HIV and Young Transgender People. Geneva: WHO. 
World Professional Association for Transgender Health. 2012. Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People, 7th Version. Elgin, IL: WPATH.  
Wylie, K, G. Knudsen, S. I. Khan, M. Bonierbale, S. Watanyusakul, and S. Baral. 2016. ÒServing Transgender People: clinical care considerations and service delivery models in transgender health.Ó The Lancet 2016; 388: 401-11. 





SPECIFIC OBJECTIVE 6.1: DEFINE CONCEPTS RELATED TO SEXUALITY, SEXUAL ORIENTATION, GENDER, GENDER IDENTITY, AND GENDER EXPRESSION
     	TIME
       30 minutes
     	METHODS
* Group exercise
     	MATERIALS NEEDED
* Flipcharts and markers 
* TrainerÕs Tool 6a: Term and Definition Cards
* Tape
     	STEPS

1. Set up the room: place flipchart pages in various places around the room. Tape Term Cards (see TrainerÕs Tool 6a: Term and Definition Cards) to the pages, leaving room for definitions. 

Time: 10 minutes
2. Introduce the topic using Content: Introduction to SOGIE below. 

Content: Introduction to SOGIE
For many service providers, few subjects can feel more difficult, confusing, or complicated than sexual orientation and gender identity and expression or SOGIE. Things like gender identity and sexual orientation, which feel basic to many people, are built into our assumptions through our language, through the way we learn, through the ways we are taught to interact with each other and our communities. Sometimes, our personal, cultural, or religious values and experiences put us into conflict with our desire to help clients who may have sexual or gender identities that feel foreign Ð even wrong -- to us. 
As providers and counselors, we must understand that there are a range of sexual orientations and identities and gender identities and expressions. Adolescence is a time of learning, when young people begin to define an individual identity, explore gender and sexuality and analyze how those pieces fit together.  An adolescent client who is struggling with their sexual or gender identity often faces not only internal conflict and confusion, but also extreme stigma, discrimination, pressure, and even violence from their society, their peers, and their families. When sexual orientation and gender identity intersect with other discrimination factors such as disability, ethnicity ad race, the risk for adolescents to experience, stigma, pressure and violence is even higher. It is the responsibility of providers to provide accurate, accessible and unbiased information and services to all adolescent clients, even if their sexual orientation, gender identity or gender expression conflicts with their personal values and opinions.
3. Tell participants that youÕll be conducting a quick exercise to help everyone in the room assess their comfort with todayÕs topic.  Ask participants to close their eyes while you ask a series of questions. Ask them to raise their hands in response if they are comfortable, but stress that no one needs to raise their hands if they do not want to. 

TrainerÕs Note: pause after each statement for participants to put their hands back down if they have raised them. Take note if any participants look uncomfortable or are not participating at all. 

4. Ask participants to raise their hands if:

a. They are usually happy with or comfortable with their assigned gender. 
b. They ever feel like they are expected to behave in a certain way because of their gender. 
c. They are ever frustrated with how someone treats them because of their gender.
d. They are married or in a relationship. 
e. They have ever struggled to find someone they felt like they could connect with. 
f. They have ever felt like someone was judging them or unnecessarily unkind to them. 
g. They feel comfortable talking about issues related to sexual orientation and gender identity and expression. 
h. They know of anyone who identifies as lesbian, gay, bisexual, transgender, or intersex. 
i. They feel capable of seeing/caring for someone who is or might be lesbian, gay, bisexual, transgender, or intersex. 
j. They feel capable of seeing/caring for someone who is or might be lesbian, gay, bisexual, transgender, or intersex and has a disability. 

5. Tell participants to take a deep breath and open their eyes again when they are ready. Ask participants to consider how they felt when answering the questions and take a moment to set aside their concerns and discomfort and open their thinking for the next session. 

Time: 20 minutes
6. Divide the group into two teams. Distribute the Definition Cards evenly between the groups. Give the groups five minutes to match the definitions on the cards with the terms taped around the room. 

7. With the whole group, review the terms and definitions according to the answer key included in TrainerÕs Tool 6a. Take time with each definition to clarify terms or answer questions and correct misinformation. 



TRAINERÕS TOOL 6A: TERM AND DEFINITION CARDS
Term Cards: 
1. Biological Sex
2. Gender Identity/Expression
3. Queer
4. Gender Norm
5. Gender Stereotype
6. Sexuality
7. Sexual Orientation
8. Lesbian
9. Gay
10. Bisexual
11. Transgender
12. Intersex




Definition Cards
Source:  Adapted from Amnesty International 2015
A. Q woman who is primarily physically, sexually, and emotionally attracted to other women. It can refer to same-sex sexual attraction, same-sex sexual behavior, and same-sex cultural identity for women. 
B. Individuals who have genital, chromosomal, or hormonal characteristics which do not correspond to the given standard for ÒmaleÓ or ÒfemaleÓ categories of sexual or reproductive anatomy. It may take many forms and covers a wide range of bodily characteristics.
C. An expected mode of behaving in society based on a personÕs real or perceived physical sex, or whether they are male or female.

D. The physical, genetic, and chromosomal characteristics that make a person physically male, female, or intersex.
E. The combination of sex, gender identity and role, eroticism, pleasure, intimacy, and reproduction. It is experienced and expressed in thoughts, fantasies, desires, beliefs, attitudes, values, behaviors, practices, roles, and relationships.
F. Men or women who are primarily physically, sexually, and emotionally attracted to people of the same sex. It can refer to same-sex sexual attraction, same-sex sexual behavior, and same-sex cultural identity. It is not gender-specific and can refer to a person of any gender who experiences same-sex sexual attraction, though in common usage it usually refers to men.
G. Individuals whose gender identity and/or gender expression is different from the biological sex they were assigned at birth. Some people may choose to modify their biological sex to match their gender identity, either through surgery or hormonal treatments, and some may not. The term can include a wide range of other identities, such as members of third genders, as well as individuals who identify as more than one gender or no gender at all.
H. A personÕs deeply felt individual experience of gender, which may or may not correspond with the sex assigned at birth, or with the way they are expected to express their gender. It includes a personal sense of the body (which may involve, if freely chosen, modification of bodily appearance or function by medical, surgical, or other means) and other expressions including dress, speech, and mannerisms.
I. A person who is attracted to and/or has sex with people of all genders. It can also refer to a cultural identity.

J. A person whose sexual orientation, gender identity, and/or gender expression fall outside the expected norm for their society, or a person of any gender whose sexuality is not heterosexual or straight. 
K. Generalized assumptions made about how a person is or should be based on their gender identity or expression. Assumptions made about peopleÕs value on the basis of their biological sex, sexual orientation, or gender identity or expression. They may not be based in fact and can be both positive and negative.
L. Refers to each personÕs capacity for emotional and sexual attraction to, and intimate and sexual relations with, individuals of a different gender, the same gender, or more than one gender.


Answer Key: 1-D, 2-H, 3-J, 4-C, 5-K, 6-E, 7-L, 8-A, 9-F, 10-I, 11-G, 12-B. 


SPECIFIC OBJECTIVE 6.2: DESCRIBE CHALLENGES, PRESSURES, AND RISKS FOR ADOLESCENTS BASED ON THEIR SEXUAL ORIENTATION AND GENDER IDENTITY AND EXPRESSION 
     	TIME
       1 hour
     	METHODS
* Group Discussion
* Trainer Presentation
     	MATERIALS NEEDED
* Slides 6.1-6.13
* Participant Handout 2a: Developmental Characteristics of Adolescence and Young Adulthood (from Unit 2)
     	STEPS

1. Ask participants to take out and revisit Participant Handout 2a: Developmental Characteristics of Adolescence and Young Adulthood (distributed in Unit 2). 

Time: 30 minutes
2. Ask participants to work quickly in pairs with the person sitting next to them to underline or highlight those characteristics of adolescent development that they think are particularly important to note for adolescents who identify as or might be lesbian, gay, bisexual, transgender, queer, or intersex. Give participants no more than 5 minutes to complete this activity. 

3. Draw participants attention to these statements on their handout in the ÒSocial and Emotional DevelopmentÓ Column: 

Early Adolescence (Ages 10-14)
* Struggle with a sense of identity
* Worry about being ÔnormalÕ
* Increased awareness of sexual desire

Late Adolescence (Ages 15-19)
* Swings in self-esteem and self-confidence
* Worry about being ÔnormalÕ
* Occasionally fluid or rapidly changing understanding of sexuality and gender
* Feelings of love and passion
* Increasing interest in sex

Early Adulthood (Ages 20-14)
* Firmer sense of sexual identity
* Development of serious romantic relationships

4. Ask participants to reflect individually on the messages they hear in their communities about sexual orientation and gender identity. Facilitate a short group discussion using the following questions: 
a. Are the messages about sexual orientation and gender identity in their communities mostly positive? Mostly negative? 
b. Are there negative or positive messages that refer specifically to sexual orientation, gender identity, and disability? 
c. When do adolescents start hearing negative messages about sexual orientation and gender identity in their community? 
d. How would those messages affect their ability to navigate their adolescence? How would those messages affect things like their self-esteem, sense of being Ônormal,Õ or sense of belonging?
e. Would those messages affect adolescents with disabilities differently?
f. What resources are available in the community for adolescents struggling with these issues? Are they accessible to adolescents with disabilities? Who can they talk to if they need to talk?

Time: 30 minutes
5. Introduce Content: Health Needs of LGBTQI Adolescents (Slides 6.1-6.13). Explain to participants that for many adolescents, their sexual orientation or gender identity or expression can put them in the path of increased harassment, discrimination, and even violence from their peers, their families, and their communities. Explain to the participants that the intersection of these discrimination factors with disability exposes LGBTQI adolescents with disabilities to a higher risk of harassment and violence. 

      Content: Health Needs of LGBTQI Adolescents (Slides 6.1-6.13)
	Sources:  Advocates for Youth 2016, IOM 2011, SAHM 2013, Amnesty International 2015

Slides 6.1-6.2: Concerns of LGBTQI Adolescents
Adolescence is a time of exploration of your place in society, including your gender, gender expression, sexuality, and sexual desire. For some adolescents who may not have a sexual orientation, gender identity, or gender expression that conforms to their societyÕs expected Ònormal,Ó this can mean extra social pressure and even harassment, discrimination, or violence from all corners. Moreover, LGBTQI adolescents with disabilities, and especially those with intellectual and developmental disabilities, often face additional barriers in expressing their sexuality or gender identity. This may affect their ability to form social and intimate relationships, and to connect with mainstream LGBTQI and disability support groups and communities. 

From a health providerÕs perspective, the health concerns of LGBTQI adolescents may be largely the same as those of their peers, but they are amplified by the additional stigma they experience related to their sexual orientation or gender identity: 
* They have questions about the changes in their bodies and emotions during adolescence.
* They face social stigmatization of their sexual desire and sexual behavior.
* They risk unintended pregnancy and infection with STIs, including HIV.
* They may be subject to sexual or gender-based violence, sexual coercion, or intimate partner or domestic violence in the household. This risk affects both their physical and mental health. 

Slide 6.3: Specific Health Risks of LGBTQI Adolescents
When it comes to unintended pregnancy and STI risk, including risk for HIV, there are some assumptions about lesbian, gay, bisexual, transgender, queer, and intersex youth that need clarification: 
* Young men who have sex with men have higher risk for HIV and other STI transmission. 
* Young women who have sex with women have lower HIV risk, but are at risk for other STIs, especially those that are transmitted skin to skin or orally. 
* Young lesbian women and young gay men may have opposite-sex partners because of social pressure or experimentation. 
* Young lesbian, bisexual, and transgender women are frequent targets for sexual violence, such as Òcorrective rapeÓ and need access to emergency contraception and post-exposure prophylaxis.  Corrective rape occurs when a person is raped because of their perceived sexual orientation or gender identity.  The common intended Òconsequence,Ó as seen by the perpetrator, is to turn the person heterosexual or to enforce conformity with gender stereotypes.  

Slides 6.4-6.8: Harassment and Discrimination
In addition to the amplified concerns of these adolescents related to sexual and reproductive health, LGBTQI adolescents also face additional harassment and discrimination. This is particularly true for persons with disabilities who identify as LGBTQI. 

Homophobic bullying in schools, in the home, and in communities can inflict psychological, emotional, and physical harm on young people who are targeted based on their real or perceived sexual orientation or gender identity. 

In Bangladesh, a 2007 study showed that boys who behave in more stereotypically ÒfeminineÓ ways are more likely to drop out of school due to harassment and bullying.
Source: Amnesty International 

Young people who Òcome outÓ to their families as lesbian, gay, bisexual, transgender, or queer may face rejection or abuse from their parents, caretakers, or other family members, increasing their risk for depression, suicide, and self-abuse. 

Young people who face rejection from their families during adolescence are 3.5 times more likely to experiment with drug use or have unprotected sex, 6 times more likely to suffer from depression, and 8.5 times more likely to report having attempted suicide. 
Source:  SAHM 2013

Adolescents who identify as LGTBQ may be forced into emotionally abusive or damaging ÒreparativeÓ therapies or may be subject to ÒcorrectiveÓ rape or sexual violence. 

One 2011 study in South Africa reported as many as 500 cases of ÒcorrectiveÓ rape of lesbian-identified women in the previous year. 
Source:  Open Society Initiative for Southern Africa

People who identify as transgender or have gender identities or expressions which are not considered ÒnormalÓ by their communities are particularly targeted for violence. 

Between January 2008 and October 2014, there were 1,612 reported killings of transgender people in 62 countries. 

Persons with disabilities who identify as LGBTQI are more likely to report having experienced harassment or violence than those without disabilities. 
One study published in Australia in 2018 reported that 46% of LGBT people with a disability versus 33% without reported having experienced at least one form of harassment or violence in the last 12 months prior to completing the survey. LGBT respondents with a disability were more likely to have been subject to verbal abuse than respondents without disability (32% versus 24%); more likely to have Ôreceived written threats of abuse including emails and graffitiÕ (11% versus 5%); more likely to have been subject to harassment (21% vs 14%); and more likely to have been subject to threats of physical violence or physical assault such as being punched, kicked, or beaten (13% vs 8%). 

Source: W. Leonard & R. Mann, 2018



6.  Pause here. Ask participants to reflect on if these statistics mean anything for their practice as health providers. Return to the presentation with Slide 6.9: Advice for Health Providers below. 

Slides 6.9-6.10: Advice for Health Providers
Source:  SAHM 2013
* Health care providers who care for adolescents should be trained in competent and nonjudgmental care for all LGBTQI youth. This includes an understanding of adolescent sexuality development, the ability to identify mental health concerns related to harassment, discrimination, and violence, and familiarity with physical and sexual health issues related to sexual orientation or gender identity and their intersections with disability, ethnicity, race and other discrimination factors. 
* Providers should understand that most LGBTQI young people are healthy adolescents and young adults. The high-risk behaviors exhibited by some LGBTQI adolescents are often reactions to social stigma and non-acceptance by peers and society, not as a result of moral failure or disease related to their sexual orientation or gender identity. 
* LGBTQI youth face harassment, discrimination, and violence in most societies, which is associated with increased risk of depression and suicide.
* LGBTQI adolescents with disabilities can also experience discrimination from within the LGBTQI and disability communities, compounding their sense of social marginalization and isolation and contributing to their increased risk of developing mental health problems.
* LGBTQI people with disabilitiesÕ experiences of systemic discrimination and exclusion are associated with reduced health and wellbeing and reduced access to services.
* LGBTQI people with disability present even higher rates of anxiety and psychological distress than LGBTQI people without disabilities and are at increased risk of self-harm. 
* Health care providers should be comfortable screening for and discussing these issues with their LGTBQI patients with and without disabilities and members of the community. 

Slides 6.11-6.12: Screening for Harassment, Discrimination and Violence
Young people may be subject to harassment, discrimination, and violence due to their sexual orientation or gender identity or expression. For many young people, this harassment can manifest in health service settings if providers are not fully informed or have incorrect information about or stereotypical attitudes towards sexuality and gender. In the case of LGBTQI adolescents with disabilities, discrimination factors that are related to sexual orientation, gender identity, and disability intersect, increasing the risk of harassment when accessing health services. Some things to remember: 
* LGBTQI young people are at more risk for depression and suicide, but the solution is not to change or hide their identity. 
* LGBTQI adolescents with disabilities face multiple challenges in finding support at the community level as, in most of the cases, health services, local LGBTQI organizations and networks are not disability inclusive. 
* No therapy or treatment has ever been proven to successfully ÒchangeÓ someoneÕs sexual identity or orientation.  Such therapies and treatments are harmful to young people. 
* Gender expression is not a symptom of sexual orientation: young men who are ÒfeminineÓ or young women who are ÒmasculineÓ are not necessarily lesbian, gay, or bisexual. 

7. Pause and ask participants if they would be comfortable counseling an adolescent client who identified as lesbian, gay, bisexual, transgender, queer, or intersex. Ask participants if they would feel the same in the case of an adolescent client with disabilities. Ask for any volunteers to offer tips to the other participants. 

8. Finish the presentation with Slide 6.13: Communicating with LGBTQI Adolescent Clients. 


Slide 6.13: Communicating with LGBTQI Adolescent Clients
Sexual orientation and gender identity are dynamic concepts, and adolescent sexuality can be fluid and change rapidly. Health providers should be cautious in assigning labels to adolescentÕs gender and sexuality. 
* Providers should ask adolescents how they self-identify and be guided by their language and self-concept. 
* Providers should be careful not to make assumptions about the gender identity of their clientsÕ sexual partners. 
* Providers should be careful to control their reaction and react in a neutral or positive manner to statements about the gender identity or sexual orientation of their adolescent clients. 
   
9. Close by asking for questions or clarifications. Thank participants for their input and attention. 




SPECIFIC OBJECTIVE 6.3: IDENTIFY SPECIFIC SERVICE AND COUNSELING NEEDS FOR TRANSGENDER AND INTERSEX ADOLESCENTS 
     	TIME
       1 hour 15 minutes
     	METHODS
* Values clarification activity
* Trainer presentation
     	MATERIALS NEEDED
* Slides 6.14-6.21
* Flipcharts and markers 
     	STEPS

1. Introduce the topic. Explain to participants that gender identity and expression can be one of the most difficult things to understand for many people especially those who are struggling with a gender identity or expression that is outside traditional social norms. 

2. Tell participants that people who identify as transgender or intersex not only face the same SRH concerns as other adolescents, but also may need special treatment or support from their health providers.  Very few providers, however, receive any training or information on how to support these clients. Even less for clients who have a disability.

Activity (Adapted from Amnesty International 2015)
Time: 45 minutes
3. Place a flipchart at the front of the room. Draw a box on the page and write the words ÒAct like a manÓ on the top of the page. 

4. Ask participants to share what comes to mind when they hear the words ÒAct like a man.Ó Use the following questions to prompt responses and record their responses in the box on the flipchart page. 
a. What do you need to do to be a Òreal manÓ?
b. What are you allowed to feel?
c. How do men behave? What expectations do your family, community, and friends have of men?

5. Place another flipchart next to the first one (or remove the first page and pin it to the wall where it is visible). On the next flipchart page, draw another box and write the words ÒAct like a ladyÓ on the top of the page.  

6. Ask participants to share what comes to mind when they hear the words ÒAct like a lady.Ó Use the following questions to prompt responses and record their responses in the box on the flipchart page. 
a. What do you need to do to be a Òreal ladyÓ?
b. What are you supposed to feel?
c. How do women behave? What expectations do your family, community, and friends have of women?

7. In the large group, or in smaller groups of 4-5, ask participants to reflect on what is written on the two flipchart pages. 

8. Use the following questions to prompt discussion: 
a. How does it make you feel to look at these gender roles and expectations?
b. Do you remember the first time someone told you to Òact like a manÓ or Òact like a ladyÓ? When do you think we start teaching children about gender expectations?
c. What happens when someone doesnÕt behave the way they are expected to because of their gender and disability?
d. What would it mean to behave in a way that was Òoutside the boxÓ when it comes to gender and disability?

9. On a third piece of flip chart paper, draw a horizontal line. Label one side ÒfeminineÓ and the other side Òmasculine.Ó

10. Explain to participants that one way to understand gender identity is to think of gender as a spectrum, from feminine to masculine. While some people have very stereotypically gendered expressions, most people have some combination of ÒfeminineÓ and ÒmasculineÓ traits. Ask participants to think about where they would place themselves if you asked them to mark their identity on the spectrum. 

11. Draw another horizontal line above the first. Label it ÒmaleÓ and femaleÓ on either end. Explain that there is also variation in physical sex, and that some people are born with physical or biological markers that are somewhere between male or female. Draw a vertical dash through the center of the horizontal line and mark it Òintersex.Ó 

12. Revisit the definition of ÒintersexÓ from the activity in 5.1: 

ÒIndividuals who have genital, chromosomal, or hormonal characteristics which do not correspond to the given standard for ÒmaleÓ or ÒfemaleÓ categories of sexual or reproductive anatomy. It may take many forms and covers a wide range of bodily characteristics.Ó
Clarify that intersex identities, or disorders of sex distinction, can take many forms and may or may not be visible in someoneÕs body. 

13. Tell participants that gender identity and expression may or may not be aligned with their physical sex. Ask how they think people around them would react if their gender identity didnÕt ÒmatchÓ their physical sex. What if someone wanted to change their physical sex or gender expression to ÒmatchÓ their gender identity?

Time: 30 minutes 
14. Begin the presentation with Content: Defining Gender and Sex (Slides 6.14-6.21), below. Tell participants that youÕll start by revisiting some of the definitions theyÕve seen before, and then discuss specific care strategies for transgender or intersex adolescents. 

> TrainerÕs Note: Ensure time for questions, clarification, and discussion with each slide. Make sure to correct misinformation, assumptions, or negative stereotypes when they appear, and ask participants to be respectful and open to each other and each otherÕs experiences. 

      Content: Defining Gender and Sex 

Slide 6.14: Gender Identity and Expression
A personÕs deeply felt individual experience of gender, may or may not correspond with the sex assigned at birth, or with the way they are expected to express their gender. It includes a personal sense of the body (which may involve, if freely chosen, modification of bodily appearance or function by medical, surgical, or other means) and other expressions including dress, speech, and mannerisms.

Identity is how you understand and feel your gender.  Expression is how you communicate your gender identity to the world around you in terms of dress, appearance, and actions. 

Slide 6.15: Intersex and Transgender 
Intersex: Individuals who have genital, chromosomal, or hormonal characteristics which do not correspond to the given standard for ÒmaleÓ or ÒfemaleÓ categories of sexual or reproductive anatomy. It may take many forms and covers a wide range of bodily characteristics.
Transgender: Individuals whose gender identity and/or gender expression is different from the biological sex they were assigned at birth. Some people may choose to modify their biological sex to match their gender identity, either through surgery or hormonal treatments, and some may not. The term can include a wide range of other identities, such as members of third genders, as well as individuals who identify as more than one gender or no gender at all.

Slide 6.16: Social Pressures on Intersex and Transgender Adolescents
Intersex and transgender adolescents may face different challenges. Intersex adolescents may or may not be aware of their identity, or it may only begin to become apparent when they reach puberty and experience changes in their hormones. Intersex identity is often invisible and intersexed adolescents may fear being discovered as intersex.  They may struggle to understand why and how their development differs from their peers. 

Transgender adolescents frequently have a strong sense of gender identity and of being ÒdifferentÓ from their peers. They may have been subject to violence or abuse in an attempt to ÒcorrectÓ their behaviors or identity and may have internalized social stigma against their gender expression. Transgender adolescents are often bullied or face violence from family, peers, and communities and are often at greater risk of suicide, self-harm, and depression. 

15. Pause and ask participants to reflect on their counseling and support role for adolescent clients presenting with confusion or depression related to their gender identity or sex development. Ask participants if and how they would adjust their counseling and support role if the adolescent client has a disability. 

Return to the presentation with Slide 6.17: Health Providers and Parents below. 

Slides 6.17-6.18: Health Providers and Parents
Because violence and discrimination are common within the family, health providers may need to act as a mediator between a client and their parents or caretakers. Even when an adolescent client has a supportive family environment, the health provider may be a trusted source for information about gender and sexual identity. Even when LGBTQI adolescents are accompanied by their parents, providers should refer to the adolescent as their main client and respect their opinion when it comes to decisions related to their sexual and reproductive health. Young persons with disabilities do not represent an exception.

Providers can help parents and caretakers by: 
* Reinforcing that intersex identities are common and physically safe for children, adolescents, and adults. 
* Reinforcing that transgender identity is no longer considered a physical or mental disorder and cannot be ÒfixedÓ through counseling, discipline, or social pressure. 
* Helping identify online or community resources for accurate scientific information and support for parents and adolescents (some are listed at the front of this unit). 

Slide 6.19: Specific Care Strategies: Intersex Adolescents

Source:  Frader et al, 2004

* Children born with physical sex differences may or may not need surgery to alter the appearance or function of their external genitalia. Health providers should consider the social and cultural context and acknowledge that surgery will not always protect against discrimination for those adolescents who differ from the Ònorm.Ó 
* If and when possible, providers should avoid surgery until the patient is old enough to determine their own gender identity and make their own choice for surgery. 
* Hormonal or chromosomal differences may need additional treatment with hormone therapy in adolescence or later in life in to accelerate pubertal development or increase fertility. 
* Parents and families should be supported to help their intersex children understand, accept, and embrace their bodies and physical differences.
 

Slide 6.20-6.21: Specific Care Strategies: Transgender adolescents 
Source:  Wylie et al, 2016
* Transgender adolescents should, whenever possible, be treated within the primary care structure, no differently from other adolescents. 
* Adolescents presenting with non-normative gender identity or transgender identity should be supported with positive counseling and mental health support for the duration of any treatment. 
* Many online resources and communities exist for transgender adolescents who do not have in-person or community support. 
* Drugs to suppress hormones can be prescribed to delay the onset of puberty or block the maturation of secondary sex characteristics while the adolescent continues to develop their gender identity and role. 
* Hormone therapies can be used to promote feminization or masculinization for transgender adolescents who are planning to transition to their experienced gender identity. 
* Providers should discuss storage of eggs or sperm to ensure opportunities to reproduce in the future.
* Providers should also discuss potential interactions of hormone therapy with HIV drugs and other medical treatments or procedures before starting any hormone regimen. 
* Gender confirming surgeries, though not currently available in most countries, may be beneficial to adolescents with gender dysphoria, which can improve psychological outcomes. 

16. Close the session by reminding participants that while many of them may not have to directly treat intersex or transgender adolescents, the awareness of these issues can help them be more understanding for all adolescents regardless of their gender identity or expression.  






SPECIFIC OBJECTIVE 6.4: MODEL INCLUSIVE COUNSELING TECHNIQUES FOR ALL ADOLESCENTS REGARDLESS OF SEXUAL ORIENTATION OR GENDER IDENTITY OR EXPRESSION 
     	TIME
       45 minutes
     	METHODS 
* Fishbowl role play
     	MATERIALS NEEDED
* TrainerÕs Tool 6b: Client descriptions
     	STEPS

1. Set chairs in a circle in the center of the room. Pull two chairs into the center of the circle, facing each other. 

Time: 45 minutes 
2. Ask for two participants to sit in the chairs in the center of the circle. Assign one the role of provider, and one the role of client. 

3. Give the client a role description card (see TrainerÕs Tool 6b: Client Descriptions below). Tell the participant playing the client to act according to the description without reading out the description to the audience.

4. Explain to the participant playing the provider and the group that the point of this exercise is to practice providing counseling in a non-judgmental and open manner. They should give accurate information that is helpful to the client. 

5. Ask the rest of the participants to observe the interaction between the ÒclientÓ and the Òprovider.Ó 

6. Have the two participants in the center of the circle spend five minutes role playing the interaction while being observed. When they have finished, ask observers to comment on the following questions: 

a. Did the provider/counselor provide accurate and helpful information to the "client" in a non-judgmental manner? 
b. If yes, what things did the "provider/counselor" do that led to a positive interaction?
c. What could the "provider/counselor" have done to improve the interaction between him/herself and the "client"?
d. Ask the "client"Ñhow the character s/he played felt in this situation?
7. Ask for two new volunteers. Give the new ÒclientÓ a description card and the same instructions. Repeat the exercise for as many client description cards as you think are relevant or necessary for practice. 

8. Close the session by thanking volunteers and the group for their participation. 



TRAINERÕS TOOL 6B: CLIENT DESCRIPTIONS 

Client 1: You are an 18-year-old woman who is attracted to women. You have known this about yourself for years and have tried to establish relationships with men, but it only makes you unhappy. Your family has made it clear that when you finish secondary school at the end of the year, you should be planning to get married. You go to the counselor/health provider for advice: you want to know if she can give you some kind of injection to make you attracted to men instead of women. 

Client 2: You are a 23-year-old man with a 4-year-old son. You recently caught him wearing his motherÕs shoes and putting on lipstick. His mother says that he sometimes does this: it doesnÕt mean anything, and he will grow out of it in year or two. You are afraid that it means that your son will grow up to be feminine, or even attracted to other men. Your mother says you should beat the behavior out of the boy, so that he knows how to be a man.  You visit the health provider to find out if your son is gay. 

Client 3: You are a 16-year-old young man who lives on the street with your younger siblings. To make money to buy food, you trade sexual favors (including anal intercourse) with other men. You have heard that HIV is only spread through sex, and you only have sex (vaginal intercourse) with your girlfriend, so youÕre not worried about catching it. Some of the older boys tease you about being Ògay,Ó and you are concerned that if you keep having sex with men for money you will end up gay. 

Client 4: You are a 17-year-old woman with a 19-year-old boyfriend. You have been seeing him for two years and having sex for over a year. You love your boyfriend and enjoy having sex with him. You also have a female best friend that you have known since you were a small child. Since you were 13 or 14, you have been kissing and ÒplayingÓ with her sexually but you never thought it meant anything about you or her being lesbian. Your boyfriend recently caught you kissing your friend and brought you to the health provider to be Òfixed.Ó 

Client 5: You are 14 years old. When you were born, everyone thought you were female, so you have been told you were a girl your whole life, but it has always sounded wrong to you. As long as you can remember, you have felt like somehow God put you in the wrong body, and you were meant to be a boy. You are different from the other girls in your community: you donÕt understand them and hate being forced to spend time with them, when you would rather be playing with boys. As you have begun to become more visibly ÒfemaleÓ which includes the onset of menstruation your family has been pressuring you to act more like a Òproper young woman.Ó You want the health provider to stop your body from physically changing so that you can go back to playing with the boys the way you did when you were a child. 

Client 6: You are an intersex adolescent with a visual disability and you are not sure yet about your gender identity. When you go to your health provider, your parents tend to discuss and make decisions about your health without consulting you. Your parents think you should have a surgery as soon as possible to ensure you fully develop as a woman, and do not miss the opportunity to get married and have someone who can take care of you when they are gone. They take you to the SRH clinic to discuss about the surgery. You are not sure you feel like a girl and you need more time. You hope the SRH provider will ask how you feel about this. 




UNIT 6 SUMMARY
     	TIME
       15 minutes
     	METHODS
       Ice-breaker
     	MATERIALS NEEDED
       None
     	STEPS

1. Gather participants in a circle. Go around the circle and have participants list one thing they like about being their gender. 

2. Go around again and have participants list one thing they would change about being their gender, if they could. 

3. Have participants reflect on any commonalities or differences. Remind participants that it is the differences between us that make us interesting.