The Journal of School Nursing2024, Vol. 40(1) 74–85© The Author(s) 2022Article reuse guidelines:sagepub.com/journals-permissionsDOI: 10.1177/10598405221120440journals.sagepub.com/home/jsn
Youth who identify as transgender or gender non-conforming (TGNC) are at greater risk than their peers for mental health concerns. School staff knowledge and training on supporting the mental health of these students may have a significant effect on this population. To better understand where school staff are provided such training, we conducted a scoping review to determine any differences in staff knowledge and training between urban, suburban, and rural high schools. We searched five electronic databases using keywords: transgender or gender variant or gender non-conforming, mental health, school, and student. Twelve articles met the criteria for review. We found no comparative studies that differentiate staff training and knowledge across high school settings. Most articles demonstrated the efficacy of training school staff in supporting TGNC students, and demand from school staff for access to such training. School nurses can lead and advocate for such training to support TGNC students.
trans youth, mental health, school nurse education, school nurse knowledge/perceptions/self-efficacy, sexual minority youth, high school
In the United States, 20% of youth have at least one mental health condition (Whitney & Peterson, 2019). Transgender and gender non-conforming (TGNC) high school students are at even higher risk for mental health conditions than their peers. Compared with cisgender lesbian, gay, bisexual, queer, and questioning youth, TGNC students are more likely to experience depressed mood, suicidal ideation, and suicide attempt (Price- Feeney et al., 2020). Many TGNC students feel unsafe in school. They experience increased levels of victimization in the school setting, including verbal and physical assault. They can also face difficulties with access to restrooms and locker rooms, the ability to use their chosen name, and other daily concerns that can make them feel unsafe. These experiences often result in poorer education outcomes for TGNC students (Greytak et al., 2009). Prevailing research suggests that school environments that affirm and support a student’s gender identity are essential for supporting and affirming TGNC students in the school setting and that the more students feel a sense of safety and belonging in school, the fewer mental health issues they report. Training and knowledge for school staff on how to support the mental health of TGNC students is critical to helping schools create inclusive, welcoming, safe environments where TGNC students can learn and thrive with better mental health.
The report from the Gay, Lesbian & Straight Education Network (GLSEN, 2012) Strengths and Silences: The Experiences of Lesbian, Gay, Bisexual and Transgender Students in Rural and Small-Town Schools found that LGBT students in rural and small-town schools have fewer supports such as comprehensive school policies, supportive school staff, and student groups. Consequently, these LGBT students have more negative experiences than their peers in urban and suburban school settings. However, it is unclear what evidence exists in the literature regarding the training and general knowledge for school staff supporting the mental health of TGNC students. We wanted to determine whether there are differences across urban, suburban, and rural settings in terms of training for school staff to support TGNC students’ mental health. “School staff” for this project refers mainly to school nurses, teachers, counselors, and administrators. We were, however, especially interested in understanding TGNC mental health training and knowledge for school nurses due to their unique ability to influence policy and implement best practices for creating safe, welcoming spaces for TGNC students.
We undertook a systematic scoping review to record research conducted in this area and to determine whether there are any gaps in the literature. Scoping reviews aid in synthesizing evidence and assessing the extent of literature on a specific topic. We formulated the following review question: What is known about the differences between urban, suburban, and rural school staff knowledge and training for mental health in transgender and gender nonconforming high school students?
This scoping review followed the Joanna Briggs Institute Manual for Evidence Synthesis, and this article was prepared using the Preferred Reporting Items for Systematic Reviews (PRISMA) developed specifically for Scoping Reviews – the PRISMA-ScR. (Tricco et al., 2018).
To be included in the scoping review, articles needed to measure, or focus on, school staff knowledge and training in high school educational settings for TGNC high school students’ mental health. Relevant peer-reviewed journal articles were searched and included if they were: (1) published between 2010–2020, (2) conducted in the United States of America, (3) written/published in English, (4) examined youth and adolescents, defined as between 12–19 years old, and (5) examined students in the high school setting. These criteria yielded 76 articles.
Studies were excluded if they lacked relevance to the review question, were completed outside of the United States, or focused on any of the following: medical or healthcare interventions, family-oriented interventions, a higher education setting, intimate partner violence, or peer relations.
Five databases were searched to capture potentially relevant documents: Academic Search Premier, APA PsycINFO, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Nursing and Allied Health Database, and PubMed. The search strategies were drafted with the aid of a distance learning librarian. The search strategy used the keywords “transgender”, “gender variant”, “gender nonconforming”, “mental health”, “school”, and“student”. The Boolean operators AND OR were used. The final search results were exported into Zotero, and duplicates were removed by the authors. Additional studies were identified using the reference lists of screened articles. As an example, the final search strategy for Academic Search Premier, one of the five databases searched, can be found in Table 1.
A data extraction table was developed by the primary investigator to create a summary of the results for each research article: The article titles and abstracts were distributed among the research team to review independently, with data being collectively appraised by all three members of the team (authors #1 and #2 and a third member who was unable to continue the study after the data collection process) when discussing article inclusion. The table was continually updated after group discussion and after information from each study was extracted by members of the research team.
After the removal of duplicates, articles were divided amongst the researchers for review of abstracts. Following analysis, researchers collectively appraised articles excluded based on abstract reviews and determined that 33 articles were appropriate for full-text review. Each of the 33 full-text articles was reviewed by one member of the team for relevance to the review question. Following independent reviews, members of the team again convened to appraise each article for inclusion in the scoping review. Following this process, another 21 articles were eliminated. Records were excluded if they were study protocols, editorials, textbooks, or handbooks. We also excluded articles that focused on sexual minorities but did not include gender minorities such as transgender youth. One article was excluded because it had been published in 2009 which was outside our date range criterion. A final sample of 12 research articles remained to frame three overarching themes: training for school staff, locale, and school climate and safety for TGNC students. The overall process and outcomes of the review are outlined in Figure 1. Reviewers then assembled authors, dates, study aim(s), population/sample, data collection method, key findings, and recommendations into a second electronic data extraction table.
Most of the 12 articles included in the final review were secondary analyses of larger surveys or reports on surveys the authors had conducted previously (Abreu et al., 2019; De Pedro et al., 2018; Demissie et al., 2018; Gower et al., 2018; Greytak et al., 2013b; Kosciw et al., 2012; Palmer et al., 2012; Williams & Chapman, 2014). Two studies used data from large surveys that were also included in the scoping review. Palmer et al. (2012) used data from the 2011 National School Climate Survey: The Experiences of Lesbian, Gay, Bisexual and Transgender Youth in Our Nation’s Schools (Kosciw et al., 2012). Additionally, Putting the “t” in “Resource”: The Benefits of LGBT-related School Resources for Transgender Youth” used data from the 2009 National School Climate Survey (Greytak et al., 2013b).
Three studies used data from only one state within the United States. Two were secondary analyses listed above: Gower et al. (2018), which conducted a secondary analysis of the 2016 Minnesota Student Survey, and De Pedro et al. (2018), which used a subsample from the 2013 − 2015 California Healthy Kids Survey. Resiner et al. (2020), conducted a mixed-methods study in Massachusetts consisting of online focus group discussions and surveys.
A study by Black et al. (2012) explored the effects of safe school programs and policies on sexual-minority youth. In Educating the Educator: Creating Supportive School Personnel Through Professional Development, Greytak et al. (2013a) reviewed the literature on in-service professional development on LGBT issues and examined the results of a district-wide training workshop for school staff such as teachers, mental health providers, school building and district administrators on bullying and harassment of LGBT youth. Wofford (2016) explored how the Winnicottian theory, which suggests that the parents’ capacity to create an environment in which an infant feels safe and supported affects maturational growth, can be used by school mental health staff to address the mental health needs of sexual and gender minority students. There were no studies that focused on the training or knowledge of school nurses regarding the mental health of TGNC students.
A synthesis of the results and details of key findings and recommendations from each article were compiled by the authors into a table (see Table 2.) While none of the articles directly addressed the review question: What is known about the differences between urban, suburban, and rural school staff knowledge and training for mental health in transgender and gender non-conforming high school students, three main themes emerged from our review that highlighted the importance of training for school staff and maintaining a safe environment for TGNC students.
A majority of school staff believe they need more training and resources to help them support TGNC students and also value training to provide peer support (Abreu et al., 2019; Black et al., 2012; Reisner et al., 2020). Training programs can enhance school staff’s ability to support and connect with TGNC youth, improve attitudes towards LGBT individuals, help ensure a safe school climate, and increase mental well-being for LGBT youth (Black et al., 2012; Gower et al., 2018;). More research is needed to determine if school nurses, in particular, receive adequate training, what their perceptions are regarding any training they are provided, and what kind of peer supports are in place.
Students in rural or small towns are least likely to experience a safe school environment and are least likely to have LGBT-related resources including supportive staff and administration or inclusive curricula (Kosciw et al., 2012; Palmer et al., 2012). De Pedro et al. (2018) found rural schools that do have LGBTQ support, peer intervention, and teacher intervention were associated with higher levels of safety among LGBTQ youth.
Greytak et al. (2013a) investigation of a large urban school district evaluated the effectiveness of educator training programs on LGBT student issues with a two-hour training workshop on bullying and harassment of LGBT youth for secondary school administrators, mental health providers, and teachers. They found professional development can effectively prepare staff to address anti-LGBT bias and to help ensure a safe school climate for LGBT youth. The authors noted that future research should explore the effects of similar trainings in a diverse array of districts including suburban and rural districts.
Youth that are transgender or gender non-conforming have higher unmet mental health needs such as anxiety, depression, and suicidal ideation than their peers (Williams & Chapman, 2014). However, TGNC youth who feel safe at school appear to have lower odds of depression and suicidality (Gower et al., 2018). In schools with good LGBTQ support, including staff support, inclusive curricula, and antibullying and/or harassment policies, TGNC students experience a safer school environment, have lower levels of student victimization, and have decreased absenteeism due to feeling unsafe at school (Greytak et al., 2013b; Kosciw et al., 2012). School climate for LGBTQ youth can be improved by teaching inclusive curricula, staff training on LGBTQ issues, and other measures (Black et al., 2012). Greytak et al. (2013a) found in their study regarding educator training programs on LGBT issues, that professional development programs can help ensure a safe school climate for LGBT youth. The effect of a student support club such as the Gay Straight Alliance (GSA) was less clear. Black et al. (2012) observed that such clubs contribute to an improved school climate. However, according to De Pedro et al. (2018) secondary analysis of the California Healthy Kids Survey, the presence of a GSA is associated with lower levels of safety. As this finding is unexpected in the context of prior research, the authors theorize that one possible explanation for this finding is that GSAs may be started in schools where there is an existing concern about safety for LGBTQ students.
The goal of this scoping review of the literature was to document and describe any differences in staff knowledge and training between urban, suburban, and rural high schools for supporting the mental health of TGNC students. Overall, our findings reveal a small body of research (n = 12) discussing school staff support of TGNC high school students’ mental health, and no studies that focused solely on school nurses.
We found that school climate can be a significant source of stress and victimization for these students. This finding aligns with current research on TGNC student experiences in the high school setting. For example, Pampati et al. (2020) surveyed seven Florida high schools and found a minority of transgender students had positive perceptions of school connectedness and safety. Most transgender students did not believe that staff cared about them or that staff treated students fairly. Less than 30% of transgender youth in the study agreed with the statement “I feel happy at school.” One way to increase feelings of safety in schools is to increase protective factors such as having supportive educators and staff. We found that the training of school staff provides protection and creates a safer school climate. (Black et al., 2012; Greytak et al., 2013a; Kosciw et al., 2012).
In a 2009 study, Kosciw et al. examined how locational, community-level, and school district-level variables relate to indicators of hostile school climate for lesbian, gay, bisexual, and transgender (LGBT) youth. They found schools in rural communities were the most unsafe for LGBT youth. Although previous studies identify urban schools as being the least safe, the authors suggest that larger, more diverse, urban schools may provide students with more opportunities for social belonging since there is more variety in social groupings. Kosciw et al. (2009) point out that more negative attitudes toward LGBT people, in general, have been attributed to a lack of diversity in rural communities and populations that tend to hold more conservative values. Therefore, we theorize that training for school staff is potentially most crucial in rural locales.
Still, no studies within this scoping review measured differences in school staff training and knowledge of supporting TGNC students’ mental health between rural, suburban, and urban settings. Further research into training and professional development for school staff in urban, suburban, and rural schools may shed further light on barriers to such training and may provide an incentive to increase opportunities for training programs.
The generalizability of study findings is somewhat limited as several of the studies reported secondary analyses of the same large surveys. In one study, Williams and Chapman (2014) analyzed data from interviews that were conducted as far back as 1995. Hence, there is a gap in the literature surrounding TGNC knowledge and training for school staff, especially school nurses, specific to the mental health needs of these students. Opportunities for future research should focus on supporting school nurses as leaders who are competent in TGNC knowledge and training.
School nurses are instrumental in addressing the mental and physical health needs of vulnerable TGNC students. Yet, there were limited findings within the scope of the literature review to support the role of school nurses’ knowledge and training in addressing mental health promotion for TGNC students. In their position statement on LGBTQ students, the National Association of School Nurses (NASN) (2021) call to action states that school nurses are uniquely positioned to support and advocate for LGBTQ youth. Interventions by school nurses such as creating LGBTQ-affirming and safe spaces, providing crisis intervention and suicide prevention resources, creating, and advocating for policies and inclusive protections, helping LGBTQ students find access to supportive medical and psychological care, and assessing LGBTQ students for bullying, violence, and family rejection, can have a positive impact on the mental health of these students (NASN, 2021). School nurses are charged by the NASN (2021) to collaborate with educational school staff/teams to create welcoming safe environments and to address the stigma, discrimination, and marginalization of LGBTQ students.
Many schools do not have ample resources to offer comprehensive education and training for nurses, let alone other school staff. To help meet these challenges, school nurses within their scope of practice can seek free online resources, continuing education courses, and training opportunities that provide culturally competent skills and knowledge to provide care and support to TGNC adolescents. When both school nurses and school staff are familiar with best practices, a safer school climate can be achieved. School nurses are in a prime position to create educational resources for school staff and students pertaining to creating safe and inclusive K-12 schools for TGNC/LGBTQ youth (GLSEN, 2012). School nurses serve as change agents to lead and advocate for the implementation of non-harassment policies, nondiscrimination policies, and inclusive health-related curricula. Gower et al. (2018) recommend that school nurses, as well as school staff, should keep lists of community organizations that can facilitate connections between TGNC youth and supportive adults in the community.
This scoping review has limitations that require acknowledgment. We wanted to focus on high schools in the United States and as such eliminated results from other countries and from elementary and middle schools. Additionally, our decision to compare urban, suburban, and rural high schools limited our scope for meaningful results. Had we chosen a less narrow focus, more data on training to support school nurses and other staff on TGNC student mental health could have been revealed. However, our findings provide a glimpse into the current research on TGNC mental health training to guide future research.
While there is more awareness, interest, and research into mental health for TGNC youth than ever, there is a dearth of literature comparing TGNC mental health training for school staff in different settings. This scoping review aimed to record research into this specific area and identify gaps. High-quality research is needed to determine what differences exist in school staff training in urban, suburban, and rural schools and districts, and how those differences may affect TGNC students and their mental health. Schools in all settings have the potential to offer interventions and training specific to the mental health, well-being, and success of TGNC youth, thus allowing school staff to potentially make profoundly positive impacts on these students. All school staff, including school nurses, have the opportunity and vision to lead these efforts.
The authors wish to acknowledge the contributions of Ashley Engebretson, DNP, RN to the search strategy and study selection.
We have no known conflict of interest to disclose.
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
The author(s) received no financial support for the research, authorship, and/or publication of this article.
Maya J.S Bastian https://orcid.org/0000-0003-2319-0065
Lindsay N. Rohlik https://orcid.org/0000-0002-2864-3230
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Maya Bastian, DNP, APRN, CPNP-PC is assistant professor in the School of Nursing in the College of Allied Health and Nursing at Minnesota State University, Mankato.
Lindsay N. Rohlik, MS, RN, PHN, is director/assistant professor in the RN to BSN Program at Southwest Minnesota State University.
1 School of Nursing, College of Allied Health and Nursing, Minnesota State University, Mankato, Minnesota, USA
2 Department of Nursing, Southwest Minnesota State University, Mankato, Minnesota, USA
Corresponding Author:Maya Bastian, Minnesota State University, Mankato, 320 Wissink Hall, Mankato, MN 56001, USA.Email: maya.bastian@mnsu.edu
