Readings

SPECIAL SECTION: DIVERSITY AND INCLUSION

A Self-Assessment Tool for Cultivating Affirming Practices With Transgender and Gender-Nonconforming (TGNC) Clients, Supervisees, Students, and Colleagues

Worner Leland1 & August Stockwell1

# Association for Behavior Analysis International 2019

Abstract In the field of applied behavior analysis, professionals are likely to interact with transgender and gender-nonconforming (TGNC) people, either as clients, in a supervision context, in the university classroom, or in the workplace. This paper presents a self- assessment checklist tool that can be used to assess one’s current behaviors of TGNC-affirming practices, along with guidance for using the tool to achieve growth in this area.

Keywords gender . LGBTQIA . transgender . ethics . self-assessment

The Need for TGNC-Affirming Practices

Currently, there are estimated to be more than 1.3 million transgender people in the United States, which accounts for approximately 0.58% of the population (Flores, Herman, Gates, & Brown, 2016). Research indicates that many chil- dren develop a sense of their gender identity by age 4; how- ever, for other individuals, gender identity is developed during adolescence or adulthood, and for others, it continues to evolve throughout the life span (de Vries, Steensma, Doreleijers, & Cohen-Kettenis, 2011; Drummond, Bradley, Peterson-Badali, & Zucker, 2008; Wallien & Cohen- Kettenis, 2008). In the 2015 U.S. Transgender Survey, 32% of respondents reported an awareness of being transgender at age 5 or younger, 28% reported it as occurring between ages 6 and 10, 21% reported it as occurring between ages 11 and 15, and 19% reported it as occurring at age 16 or older (James et al., 2016).

Professionals in the field of applied behavior analysis are in a unique position to offer support and affirming services to transgender and gender-nonconforming (TGNC) clients, stu- dents, supervisees, and colleagues, given the multiple barriers that TGNC people in the United States experience overall.

These barriers include limited access to medical and mental health care, housing, and employment (National Center for Transgender Equality and the National Gay and Lesbian Task Force, 2011). In response to the 2015 U.S. Transgender Survey, 23% of individuals noted that they avoided seeking critical health care in the past year because of a fear of mis- treatment as a transgender person, and 25% experienced prob- lems with their insurance in the past year related to being transgender, such as being denied coverage for care related to gender transition (e.g., hormone replacement therapy; James et al., 2016). In the area of mental health care, TGNC people experience high rates of suicide and emotional distress. On the U.S. Transgender Survey, 40% of respondents reported attempting suicide at some point in their life, nearly nine times the percentage of the overall population’s reported suicidality, with people of color—Black (47%), Latinx (45%), Native Hawaiian/Pacific Islander (52%), and American Indian and Alaska Native (57%) respondents—experiencing even higher rates than this average (James et al., 2016).

TGNC people also experience workplace discrimination at disproportionately high levels. According to the 2015 U.S. Transgender Survey, 27% of those who had held a job in the past year reported being fired, denied a promotion, or being passed over for a position because of their gender identity or expression, and 15% reported experiencing verbal harass- ment, physical violence, or sexual assault at work. Additionally, 23% reported other types of mistreatment, such as being forced to use a bathroom that didn’t align with their gender identity, being required to present as the wrong gender

* Worner Leland [email protected]

1 7010 N Ashland Ave., Chicago, IL 60626, USA

https://doi.org/10.1007/s40617-019-00375-0 Behavior Analysis in Practice (2019) 12:816–825

October 2019Published online: 28

to keep their job, and having a boss or coworker share private information about their transgender status without permission. Of those respondents who were employed, over half shared that they had to hide their identity and nearly half did not ask their employer to use their personal pronouns (James et al., 2016).

The majority of respondents (77%) who were perceived as transgender at some point between kindergarten and Grade 12 (K–12) experienced mistreatment. Fifty-four percent reported verbal harassment in K–12, 24% reported being physically attacked in K–12, and 13% reported that they were sexually assaulted in K–12 because they were perceived to be trans- gender (James et al., 2016). Finally, 30% of U.S. Transgender Survey respondents reported experiencing homelessness at some point in their lives, a rate three times that of the overall U.S. population. Of these respondents, 70% of those who stayed in a shelter within the previous year reported some form of mistreatment based on their gender identity or expres- sion, including verbal harassment, physical harassment, and sexual assault.

The purpose of this paper is to introduce a self-assessment tool to cultivate affirming practices with TGNC clients, supervisees, students, and colleagues that can be used by su- pervisors, supervisees, instructors, therapists, and students in the field of applied behavior analysis. TGNC-affirming prac- tices align with the Behavior Analyst Certification Board’s Professional and Ethical Compliance Code for Behavior Analysts (2017; hereafter referred to as the BACB Code), specifically with code elements 1.01, 1.02, 1.04, 1.05, 2.0, 2.02, and 9.02. It is important to note that we as professionals cannot always tell whether a person is TGNC based on ap- pearance alone, so the TGNC-affirming practices outlined in this paper should be implemented consistently across all situ- ations and not only in situations in which a client, colleague, supervisee, or student is “read” as being TGNC. Moreover, the creation of TGNC-affirming therapeutic, educational, and workplace environments is beneficial for all individuals, not only those who are TGNC (e.g., diverse and TGNC-affirming workplaces have more productive employees with higher job satisfaction; Badgett, Durso, Kastanis, & Mallory, 2013; Catalyst, 2014).

Terms and Definitions

To provide context for the foregoing assessment tool, this section includes several terms and concise definitions.

First, gender identity refers to a person’s sense of their covert experience of being a woman/girl, man/boy, some com- bination of the two, neither, or something else altogether (American Psychological Association [APA], 2011). Gender identity is different from a person’s sex assigned at birth (i.e., male, female, or intersex, a label given to a baby at birth based

on the appearance of their external genitals). For the majority of people, the sex they are assigned at birth aligns with their gender identity in a way that is expected by the larger society in which they live (e.g., male and man, female and woman), which is referred to as being cisgender (cis being a Latin prefix for “on the same side of”; Aultman, 2014). For others who are transgender (trans being a Latin prefix for “across,” “beyond,” or “through”), their gender identity is different in some way from their sex assigned at birth. Many transgender individuals have a binary gender identity of either man or woman. Many others have a nonbinary identity: that is, either on a spectrum between the two binary genders (genderqueer, genderfluid, genderflux, or many other terms describe this) or outside of a spectrum concept (such as agender or no gender; Richards et al., 2016). Of the 27,715 respondents from the 2015 U.S. Transgender Survey, 29% reported being transgen- der men, 33% reported being transgender women, and 35% reported a nonbinary identity using a variety of terms (James et al., 2016).

The term gender nonconforming (GNC) is used to describe a person’s gender identity or behavior that falls outside those that are commonly accepted gender roles for men and women (this may also be referred to as gender variant or gender expansive; APA, 2011). In this paper, the acronym TGNC will be used to refer to transgender and gender-nonconforming people as a group, although there is variation both within and across these two groups. Although one may use transgender or gender nonconforming as an umbrella term to describe their identity or behavior, each TGNC individual will have vastly different learning histories and may use ter- minology to describe their experience in different ways from other TGNC individuals. Comparably, whereas some individ- uals may use both the terms transgender and gender nonconforming to describe themselves, others may find that only one, or perhaps neither, of these resonates with their experience and may use different terminology to more accu- rately represent themselves.

Gender expression is a term used to describe ways in which a person presents to the world in terms of their physical ap- pearance (e.g., clothing, haircut, makeup), behavior (e.g., voice, physical movement), and other social variables (APA, 2011). Both cisgender and TGNC people have a variety of gender expressions, and gender expression is influenced by myriad factors (e.g., access to resources, safety, preference), and because of these factors, it is not possible to identify a person’s gender identity simply by observing their gender ex- pression (APA, 2011). For additional context and background on the concepts of gender identity, gender expression, and sex assigned at birth, including the concept of intersex, please see APA (2008, 2011).

As conceptualized by the authors, TGNC-affirming practices are those that allow TGNC people to access valued reinforcers and resources at similar rates to those of their

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cisgender peers, while minimizing coercive contingencies, such as accessing basic human rights contingent on performing certain gender roles or presenting as cisgender. We also conceptualize TGNC-affirming practices as practices that enable people to access care (mental health, behavioral health, medical, etc.), as well as support their authentic verbal behavior and expand networks of choice (e.g., gender presen- tation, educational and workplace trajectories). TGNC- affirming practices can occur at the individual level (e.g., a behavior therapist providing a variety of potentially reinforc- ing items to clients, and not only items typically associated with a client’s perceived gender). However, they also encom- pass organizational policies and procedures that operate at the macro level (e.g., universities that include multiple gender identity options on admissions documents rather than a forced choice between only male and female).

Finally, the authors encourage working from the standpoint of cultural humility. Contrasted with cultural competence, which can involve the goal of mastering a specific body of knowledge, cultural humility incorporates a lifelong commit- ment to self-evaluation and self-critique (Tervalon & Murray- Garcia, 1998). Given the ways in which language and other cultural practices rapidly evolve over time, a cultural humility approach allows professionals in the field of applied behavior analysis to self-monitor and build TGNC-affirming practices that are sensitive to the individuals involved and the context in which the interactions occur. A lens of cultural humility in- vites behavior analysts to engage in ongoing assessment of their TGNC-affirming practices and also to center clients as experts on their own experiences.

Opportunities for Behavior-Analytic TGNC-Affirming Practices

Researchers are now beginning to acknowledge the role of the environment in creating and maintaining barriers for TGNC people. Such environmental variables include stigma and prej- udice (Bockting, Miner, Swinburne Romaine, Hamilton, & Coleman, 2013; Clements-Nolle, Marx, & Katz, 2006) and rejection by families, friends, and community (Koken, Bimbi, & Parsons, 2009; Russell, Ryan, Toomey, Diaz, & Sanchez, 2011). Additional examples include hostile educa- tion and workplace environments in which safe access to bath- rooms is not provided and medical and mental health care systems that involve practices that are not inclusive of, and may be harmful to, TGNC people.

In addition to environmental factors that negatively influ- ence TGNC people, nurturing environmental conditions, such as social supports, are directly related to improved mental health for transgender adolescents and adults (Almeida, Johnson, Corliss, Molnar, & Azrael, 2009; Bauer, Scheim, Pyne, Travers, & Hammond, 2015; Budge, Adelson, &

Howard, 2013; Grant et al., 2011; Ryan, Russell, Huebner, Diaz, & Sanchez, 2010; Simons, Schrager, Clark, Belzer, & Olson, 2013). Furthermore, socially transitioned children who have family and community support of their identity (i.e., those who are able to use a new name and pronouns, dress in a way that aligns with their gender identity, etc.) experi- enced normative levels of depression and minimal elevations in anxiety when compared with the overall population rate (Olson, Durwood, & McLaughlin, 2016).

The role of the environment in affecting the lives of TGNC people presents an opportunity for professionals in the field of applied behavior analysis to fill a critical and impactful role of improving the lives of their TGNC colleagues, students, supervisees, or clients. In addition to verbally stating one’s commitment to diversity and acceptance of TGNC people, skill development and changes at the systemic and organiza- tional levels are needed in order to fully address the aforemen- tioned barriers TGNC people face.

Skill development in the area of TGNC-affirming practices is supported by the BACB Code. For example, behavior ana- lysts are required to work in the best interests of their clients (BACB Code 2.0) and avoid discrimination against individ- uals or groups based on gender (BACB Code 1.05). Additionally, behavior analysts should continue to work to build their knowledge base and skill set related to TGNC- affirming practices (BACB Code 1.01) and seek out training and consultation in order to work within their scope of com- petence when serving TGNC clients, being mindful of both their unique needs and barriers to service (BACB Code 1.02).

Recommendations for Self-Assessment

Fong, Catagnus, Brodhead, Quigley, and Field (2016) sug- gested developing culturally competent self-awareness through discussion with mentors and colleagues, mindfulness practices, adherence to scientific-mindedness, and the use of self-assessment tools to become aware of personal bias. In addition to the use of personal awareness self-assessment tools, ongoing self-assessment of one’s environmental ar- rangements and skills also helps professionals identify areas for growth and informs observable, measurable goals for change (Fong et al., 2016). Criterion-referenced self-assess- ment also has the added benefits of allowing for the observa- tion of behavior that may not be easily accessible to an outside observer (Mace & Kratochwill, 1988), serving as an establish- ing operation for behavior change (Andrade & Du, 2007), and occasioning self-identification of routes for effective behavior change (Ross, 2006).

Given the value and potential impacts of self-assessment and the barriers TGNC people face, we developed the TGNC- Affirming Clinical Skills Self-Assessment (TGNC-ACSSA; see Table 1). The TGNC-ACSSA is a 28-item behavior-

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Table 1 TGNC-Affirming Clinical Skills Self-Assessment Tool

Ethics Y / N 1. I do not knowingly engage in behavior that is harassing or demeaning to persons based on their gender identity, gender expression, or gendered

preferences, interests, or behaviors. Y / N 2. I work within my boundaries of competence, and seek appropriate consultation, supervision, training, and study when working with TGNC

clients, or clients with gender-nonconforming preferences, interests, expressions, or behaviors. Y / N 3. I arrange the environment to promote truthful and honest behavior in others, including truthful and honest behaviors about gender identity,

gender expression, and gendered preferences or interests. Y / N 4. I operate in the best interests of my primary client, with reliance on scientific knowledge regarding best health and happiness outcomes for

TGNC clients. Y / N 5. If a client expresses interest in medical knowledge regarding gender or gender transition, I recommend seeking medical consultation and have a

referral network of affirming providers. Y / N 6. I promote an ethical behavior-analytic culture by disseminating my commitment to TGNC-affirming practices, as well as steps for

TGNC-affirming practices. Y / N 7. I promote an ethical behavior-analytic culture by implementing TGNC-affirming practices with my colleagues and when representing my field. Y / N 8. If I conduct research, I conduct competently and with due concern for the dignity and welfare of participants, by taking care not to exclude

TGNC participants (e.g., by using inclusion criteria language like “men and women” that may leave out people who do not fall into either category) unless there is a specific reason to do so.

Y / N 9. If I conduct research, I conduct competently and with due concern for the dignity and welfare of participants, by making sure to accurately provide participant-identified information on gender.

Y / N 10. If I conduct research, I conduct competently and with due concern for the dignity and welfare of participants, by making sure to use the correct pronouns selected by the participant for use through the entire paper and when presenting data in any modality.

Y / N 11. If I conduct research, I conduct competently and with due concern for the dignity and welfare of participants, by assessing social validity in an ongoing manner, and adjusting the study based on participant feedback whenever possible.

Environment Arrangement Y / N 12. Intake documents, employee contracts, demographic forms, and any other paperwork documenting gender offer fill-in-the-blank options for

gender, personal pronouns, and honorifics. Y / N 13. Intake documents, employee contracts, demographic forms, and all other paperwork have a space for a person’s used name, and a separate

space for a legal name. Y / N 14. On intake forms and during intake sessions, as well as on employee or supervision contracts and in interviews, it is made clear that we will use

whatever name is provided by the individual, and that their legal name will only be accessible to those involved with billing, payroll, or human resources.

Y / N 15. On our website and in print material it is made clear that the organization does not discriminate on the basis of gender, gender identity, or gender expression.

Y / N 16. In marketing material, a wide variety of genders is represented. Y / N 17. The organization has an all-gender bathroom, or a written statement that anyone may use the bathroom that aligns with their identity, or both. Y / N 18. The organization clearly displays stimuli that indicate a commitment to TGNC-affirmation, like safe zone stickers, or comparable signs,

pronoun pins or stickers, and personal pronouns listed in employee e-mail signatures. Behavior Arrangement Y / N 19. Until someone shares gendered pronouns with me, I take care to use gender-neutral language and pronouns for them. Y / N 20. When addressing groups, I use gender-neutral language, like “Hello, everyone,” or “How are you all?” instead of “Hello, gentlemen,” or

“How are you ladies?” Y / N 21. When meeting someone new, I share my name and personal pronouns. Y / N 22. I do not engage in any practice or intervention that attempts to use behavior-analytic techniques to change a client’s gender identity, or to

punish or extinguish behaviors that do not align with the gender they were assigned at birth. Y / N 23. When conducting preference assessments or reinforcer assessments, I make a wide variety of items typically associated with all genders

available for all clients, regardless of gender. Y / N 24. When working with groups, I make a wide variety of potentially reinforcing items are available to all, not only items typically associated with

a person’s perceived gender. Y / N 25. In teaching materials I use or create, as well as in scenarios or instruction I present, a wide variety of genders are presented engaging in a wide

variety of activities or occupations, not only ones typically associated with a specific gender. Y / N 26. When teaching body parts, I use accurate terminology like “penis” and “vulva” instead of gendered terms like “boy parts” and “girl parts”, and

do not rely on topographical assumptions or gendered stereotypes to teach stimulus discrimination between genders like male, female, and other genders.

Y / N 27. When conducting parent or staff training, I teach and model skills of inclusion and gender affirmation. Y / N 28. I assess the social validity of my practices as a provider, educator, employer, supervisor, and/or researcher in an ongoing manner by asking if

there is anything I can do to be more affirming, and I implement changes based on feedback.

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analytic measurement tool with subdomains for ethics, envi- ronmental arrangement, and behavior arrangement. This tool may serve as a starting point for behavior analysts to build TGNC-affirming practices. It can be used by individuals or organizations to assess skill development and consistency of implementation at the level of the clinician, supervisee, or organization as a whole in order to establish or further im- prove TGNC-affirming practices that are aligned with the BACB Code.

Tool Development and Assumptions

Although in the fields of medicine and psychology there are many standards-of-care guides that serve as a reference for providers and outline best practices for working with TGNC patients (e.g., APA, 2015; Deutsch, 2016; World Professional Association for Transgender Health, 2011), there is little in the way of self-assessment for TGNC-affirming practices. The TGNC-ACSSA is informed by a literature review on the com- ponents of TGNC-affirming standards of care in the fields of psychology and medicine. Both of the authors of this assess- ment tool self-identify as transgender or gender nonconforming and have worked closely with TGNC clients through service provision and collaborative, community- based research, and these professional interactions have in- formed the creation of this tool and the specific items includ- ed. Although assessments on attitudes, beliefs, and bias exist (Roysircar, 2004; Wang-Jones, Alhassoon, Hattrup, Ferdman, & Lowman, 2017), this tool specifically targets observable and measurable behavior and is implementable in a self- assessment format. Additionally, the TGNC-ACSSA is the first tool of its kind created for use in the field of applied behavior analysis.

How to Use the Tool

The TGNC-ACSSA serves as an ongoing assessment of one’s skills in utilizing the BACB Code, arranging environments, and engaging in behaviors that can be categorized as TGNC affirming. The tool can also be used as a guideline for choos- ing areas for growth and planning specific goals. This tool can be self-administered by anyone and is specifically designed for those who provide behavior-analytic services in human service settings.

The TGNC-ACSSA is broken down into three subdomains: ethics, environment arrangement, and behavior arrangement. Each subdomain contains a series of questions, with accompanying yes or no answers. Some of the questions may not be applicable to the self-assessor and can be skipped. For example, if the self-assessor does not conduct research, Questions 8–11 will not be applicable and can be skipped.

Ethics

The ethics subdomain asks the self-assessor to consider 11 items tied to the BACB Code. What follows are some exam- ples of when one may answer yes or no to items in this sub- scale. These examples are by no means exhaustive but will serve as a good starting point for considerations when filling out the TGNC-ACSSA.

Question 1 asks about the self-assessor’s behavior of re- spect and affirmation through a lack of behavior that is harassing or demeaning when considering others’ (a) gender identity, (b) gender expression, (c) gendered preferences, (d) gendered interests, or (e) gendered behaviors. Examples of discrimination based on gender include explicit behaviors such as refusal of care, exclusion, harassment, and violence (APA, 2011). However, discrimination may also take the form of restricting gender presentation, targeting behaviors for de- crease simply because they are gender nonconforming, or fail- ing to provide environments, learning materials, or putative reinforcers that are TGNC affirming. If self-assessors have engaged in behavior such as using slurs, mocking others’ gen- der or gendered preferences, or disallowing someone to en- gage in activities, dress, or mannerisms because of gendered expectations, they will likely answer no to Question 1.

Question 3 addresses Code 1.04(a) (BACB, 2017) and pro- moting truthful and honest behaviors about gender identity, gender expression, and gendered preferences and interests. Self-assessors who do not punish responding outside of social norms, who use gender-neutral language when asking ques- tions (e.g., asking about someone’s spouse instead of about their husband or wife), and who use clear antidiscrimination language and policies may likely answer yes to this question.

Question 4 addresses Codes 2.02 and 1.01 (BACB, 2017) and relying on scientific knowledge regarding best practice outcomes for TGNC clients (Almeida et al., 2009; Bauer et al., 2015; Budge et al., 2013; Grant et al., 2011; Olson et al., 2016; Ryan et al., 2010; Simons et al., 2013). Self- assessors who center and affirm their primary client and who recognize transgender identity and gender nonconformity as natural forms of human variation (Bagemihl, 1999) may likely answer yes to this question. Self-assessors who center the wishes of caretakers, staff, or other vested parties who may wish to restrict a client’s right to self-identify their gender or expression will likely answer no to this question.

Questions 8–11 address Code 9.02(c) (BACB, 2017) re- garding the ethical design, conduct, and report of research and the dignity and welfare of the participants. Self- assessors should only complete this section if they conduct research. For those who do conduct research, self-assessors who take care to use inclusive participant criteria language and as such are careful not to leave out nonbinary participants may likely answer yes to Question 8. Self-assessors who use binary, gendered participant criteria language (e.g., men and

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women as opposed to people) will likely answer no. Self- assessors who design studies that accurately collect participant gender identity data and personal pronouns and accurately use this information when reporting study results are likely to answer yes to Questions 9 and 10. Self-assessors who only offer binary gender options in their research data collection or who fail to collect this information and make assumptions about participants’ genders and pronouns when reporting are likely to answer no.

Environment Arrangement

The environment arrangement subdomain asks the self- assessor to consider seven items tied to permanent products in the environment that signal a TGNC-affirming space. Questions 12–14 consider forms and documents, as intake interviews should include questions that allow for clients to share all aspects of their identities, which in turn should in- form the assessment process and selection of supports that will be affirming (Fong et al., 2016). Questions 15–18 consider environment arrangements for organizations. Some of these questions may not be applicable to independent practitioners and may be skipped.

If they are using forms that only have checkbox options for gender or honorifics (such as “male” and “female” or “Mr.” and “Mrs.”), self-assessors are likely to answer no to Question 12. If they are using forms that have the option to fill in the blank for gender and honorifics and that also have fill-in-the- blank space for personal pronouns, self-assessors are likely to answer yes to Question 12. If they are using forms that have space for both one’s legal name and one’s actual name to be used and that make clear in writing that one’s actual name to be used will be honored by all personnel, self-assessors are likely to answer yes to Questions 13 and 14 respectively.

Behavior Arrangement

The behavior arrangement subdomain asks the self-assessor to consider 11 items tied to operant behaviors of TGNC affirma- tion. Questions 19 and 20 address using gender-neutral lan- guage. For many TGNC people, the wrong gendered term is used for them, or gendered terms don’t apply to them at all (Gridley et al., 2016).

For behavior reduction, it is crucial to examine the social validity of behaviors targeted for decrease. It is inappropriate to target a behavior for reduction just because it does not align with gender norms or expectations (Nordyke, Baer, Etzel, & LeBlanc, 1977; Winkler, 1977). It is also important to consid- er all the ways that behavior analysts can train affirming and supportive skills in the client’s community and assertiveness and self-advocacy on the part of the client, as opposed to

trying to align a client’s behavior with gender expectations based on a rationale that a community may not be affirming (Russell & Winkler, 1977). This is a departure from some published work in the field of behavior analysis historically (both applied and theoretical; e.g., Malott, 2015; Rekers & Lovaas, 1974; Rekers, 1977) and is in line with ethical best practice across a variety of helping professions (American Medical Association, 2018; Daniel & Butkus, 2015; Scasta, Bialer, & APA, 2013; Whitman, Glosoff, Kocet, & Tarvydas, 2006). A self-assessor who attempts to punish or extinguish client behaviors that do not align with the gender the client was assigned at birth is likely to answer no to Question 22. A self-assessor who refuses to use behavior-analytic techniques to attempt to change a client’s gender identity or gender- nonconforming behaviors and who advocates for the client’s rights with parents, caregivers, staff, and other vested parties is likely to answer yes to Question 22.

Preference assessments, reinforcer assessments, and func- tional assessments should all be informed by the idiosyncra- sies of the client and should never be based on assumptions about the client’s gender. For preference assessments and re- inforcer assessments, it is important to provide a wide array of putative reinforcers and to not restrict this pool based on gen- der norms. It is important to identify potent reinforcers, and the less preemptive restriction of potential stimuli on the part of helping professionals and caregivers, the better. A self- assessor who provides a wide array of stimuli for both assess- ments and group play is likely to answer yes to Questions 23 and 24 respectively. A self-assessor who provides stimuli based on assumptions about a client’s gender (e.g., dolls, prin- cesses, and pink for clients assumed to be girls, and trucks, superheroes, and blue for clients assumed to be boys) is likely to answer no to Question 23. A self-assessor who restricts access to stimuli in groups based on gender (e.g., telling a client that the dress-up clothing is only for the girl partici- pants) is likely to answer no to Question 24.

For skill building, it is crucial to include diverse examples in scenarios and teaching, including examples of children and adults with behaviors and interests outside typical gender ex- pectations or the gender binary (Montgomery, 2001). It is also important to be cognizant of how behavior analysts teach typ- ically gendered body parts and stimulus discrimination based on gender assumptions. Self-assessors who create and use stimuli depicting people of a wide variety of genders partici- pating in a wide variety of activities or occupations are likely to answer yes to Question 25. Self-assessors who do not teach topography-based gender stimulus discrimination and who use accurate terminology for teaching body parts (e.g., penis and vulva) are likely to answer yes to Question 26.

Question 27 addresses building the affirming skills of par- ents, caregivers, staff, and the community either formally or informally. Behavioral skills training, which consists of in- struction, modeling, practice opportunities, and feedback

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(Miltenberger, 2004), may impact the degree of access to re- inforcement a TGNC client has in their natural environment. Instruction may include clear information on antidiscrimina- tion policies or clear rules such as “You can choose any toy you like.” Modeling can include restating rules or policy (e.g., “Actually, we let clients pick whatever they like.”) or affirming feedback for clients (e.g., “That looks like a cool choice.”) in the presence of other vested parties. Practice op- portunities for this skill on the part of other vested parties involve continuing to provide opportunities for gender- nonconforming behavior to occur by providing the client ac- cess to a wide variety of stimuli. Feedback can include cor- rection of vested-party behavior (e.g., “Everyone here can pick whatever they like.”) or praise for affirming behavior (e.g., “It’s great to have such cool and affirming people around.”; Leland, 2016). Self-assessors who intentionally teach and model TGNC-affirming behavior are likely to an- swer yes to Question 27.

Tool Scoring and Goal Setting

After completing the TGNC-ACSSA for oneself or one’s or- ganization, the self-assessor can calculate the total score by dividing the number of questions answered yes by the number of questions answered and then multiplying the total by 100 to yield a percentage. The total score is a general marker of organizational performance only. It is important to emphasize the TGNC-ACSSA is not designed to provide ranking-based self-judgment, but rather to allow for self-reflection and to provide a clear representation of areas for growth. Self- assessors are invited to first review the questions they marked yes and to assess and celebrate their strengths. After this, self- assessors are invited to review the questions they marked no and to use these questions to guide the creation of a plan for growth.

When choosing a plan for growth, there are three “must pass” questions that should be addressed before any other components are prioritized: Questions 1, 2, and 22. If an- swered no, these questions should be prioritized because en- gaging in behavior that is harassing or demeaning to TGNC people and attempting to punish or extinguish gender- nonconforming behavior are both behaviors that cause direct harm to TGNC people. Additionally, working outside of one’s boundaries of competence with no supervision is also likely to cause harm to TGNC clients in ways that the self-assessor may not be aware of due to a lack of experience.

After addressing Questions 1, 2, and 22 (if necessary), self- assessors may review any other questions they marked no and may choose to prioritize items for change based on a consid- eration of organizational and individual needs. Every situation is unique, and it is important that the self-assessor takes into account what changes have the potential to be most impactful

to the organization or individual based on anticipated contex- tual factors. For example, an organization that hopes to make quick change and build momentum in organizational change may choose to prioritize items that are easy to implement, such as updating paperwork (Questions 12 and 13), adding personal pronouns to e-mail signatures (Question 18), and working on using gender-neutral language (Questions 19 and 20). An organization with specific, current contextual fac- tors, such as younger clients who routinely access shared play items and learning materials that may be gendered, may choose to prioritize items directly tied to this context, such as making a wide variety of reinforcers available to clients of all genders (Questions 23 and 24); creating new, affirming materials (Questions 25 and 26); and training staff and other vested parties to be affirming of gender-nonconforming choices and behaviors that clients may express (Question 27). Finally, an organization experiencing growth or change may choose to prioritize areas for growth with the greatest potential impact, such as creating clinic space with gender- neutral bathroom access (Question 17), putting into place and advertising a clear antidiscrimination policy (Question 15), or building strong human resource and billing practices that protect client confidentiality with regard to legal names and gender markers (Question 14).

Regardless of which route a self-assessor chooses to take to prioritize and implement TGNC-affirming change, it is impor- tant to maintain a lens of cultural humility, noting that this assessment does not attribute permanent states or mentalistic traits of TGNC affirmation in that this assessment does not serve as a yardstick with which one can score oneself as being an “affirming person,” an approach that could potentially limit ongoing professional growth. Instead, this tool should be used to assess observable and measurable behavior, as well as changes to this behavior over time. As such, the tool should be used to set observable and measurable goals and should be revisited over time to assess the fidelity of change implemen- tation and to review systems changes in order to continuously improve on TGNC-affirmation processes.

Conclusion

Given the barriers experienced by TGNC people, those in the field of applied behavior analysis can have a critical role in combating discrimination and promoting equity of access to resources. This paper provides a self-assessment tool that tar- gets concrete TGNC-affirming practices, at both the individ- ual and the organizational levels, specific to those who work in the field of applied behavior analysis. The TGNC-ACSSA is by no means comprehensive. However, it serves as a starting point for self-reflection and tracking ongoing im- provements in behavior that will have a direct and positive impact on TGNC people, whether they are clients,

Behav Analysis Practice (2019) 12:816–825822

supervisees, students, or colleagues. Rather than focus on at- titudes or values (meaningful in their own right), this self- assessment was designed to align with the core values of ap- plied by behavior analysis by targeting observable and mea- surable behaviors that can be assessed and targeted for change (Cooper, Heron, & Heward, 2007). The items delineated in the self-evaluation tool align with the BACB Code, as de- scribed previously.

The TGNC-ACSSA also prioritizes the immediate change of three critical areas to promote TGNC-affirming practice— harassing or demeaning TGNC people, targeting gender- nonconforming behavior for decrease, and working outside of one’s boundaries of competence—as all three of these are likely to cause the most harm to TGNC individuals. Aside from these three areas, respondents are encouraged to priori- tize items for improvement that are both feasible and mean- ingful, as well as those that are contextually the most appro- priate given one’s organization or professional relationships. The tool should be used to set observable and measurable goals and should be revisited over time to evaluate the fidelity of change implementation and to assess for organizational drift, rather than be used only as a one-time tool to detect the presence or absence of affirming practices.

Through continued work in the service of building TGNC- affirming practices, professionals are likely to improve the services provided to clients, students, and supervisees, as well as strengthen rapport and buy-in and increase retention. It remains to be seen whether this tool is sufficient to assess and facilitate skill development for professionals in a variety of roles (i.e., supervisor, therapist, educator, student, col- league, etc.) or if multiple, specifically tailored versions of this tool are warranted for each role or environmental context. Certainly, a single tool is not likely to reflect all professional situations that a respondent will encounter. Additionally, al- though the points included in the assessment are derived from community feedback and empirical research, no data currently exist on the utility of the checklist or its direct and indirect impact on behavior (i.e., on either the behavior of the self- assessors or the TGNC people with whom they are interacting). Because of this, research is needed to validate the use of this tool and to answer the following questions: What are the ways in which this self-assessment can be used most effectively? Are the items sufficiently specific and mean- ingful in terms of occasioning meaningful behavior in the appropriate contexts? Is a single tool sufficient for self- evaluation by those operating in a variety of professional roles in the field of applied behavior analysis, or is there a need to separate out and tailor different versions of the tool to the specific contexts of interacting with colleagues, working with clients, working with supervisees, instructing university stu- dents, and so on?

The aforementioned self-assessment tool underscores the need for continued training and supervision in the area of

TGNC-affirming practices, as well as the importance of connecting to resources as these skills continue to be devel- oped in the service of clients, supervisees, students, and col- leagues. This is an ongoing process, and the authors encour- age operating from the standpoint of cultural humility: notic- ing one’s initial reactions from a nonjudgmental perspective and remaining committed to acting positively based on one’s values around ongoing development of TGNC-affirming practices (Lillis & Hayes, 2007).

Author Note Worner Leland, Upswing Advocates, 7010 N Ashland Ave. Chicago IL, USA

Funding This article does not contain any funded research.

Compliance with Ethical Standards

Conflict of Interest The authors declare that they have no conflicts of interest.

Ethical Approval This article does not contain any studies with human participants or animal participants performed by any of the authors.

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