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Gender identity is an area increasingly explored by individuals of all ages. More people are able to verbalize that they are born in a body that does not align with the gender they identify with. Because our world as a whole is speaking more openly about gender, many adolescents can explore their identity more safely and comfortably.
For parents and support systems, this can be a difficult process and therapists may play a beneficial role helping children and adolescents to live congruently, while helping the family system to accept changes.
Normalizing the family system’s experience and emotions
It is a normal part of the process for families of children exploring their gender for the first time to struggle emotionally. This can take many forms, even if the family is accepting of these changes right away. There is a grieving process for the family as they lose the idea of what their child would have been in the future, which may need to be normalized and highlighted to some families.
It can be a confusing experience to accept these changes and experience grief at the same time, but normalizing the existence of both of these experiences can help to reduce shame. Normalize the existence of other feelings, like joy, at seeing one's child thrive in new ways is also a fundamental component of the therapy.
You can help the family gain a better understanding of the client’s experience. Provide psychoeducation to help loved ones grasp what it means to question your gender. Emphasize how important it is for family members to validate a child’s experience. Even if family members struggle to accept, you can encourage families to express their beliefs and feelings in private, away from the child, and to show as much acceptance toward the child as possible.
In an effort to explain gender to families, we can think about kids through a developmental psychology lens. Children go through the experience of developing self confidence, which transitions to identity development in adolescence. When developmental processes are interrupted, individuals become 'stuck' and develop negative self-beliefs based on parts of their identity that others do not accept.
The result is a cognitive dissonance for the child - they have a sense of who they are, but believe they cannot be that person. Families who validate the identity of trans youth help them move healthily and functionally through these stages, increasing the likelihood of high self-esteem and an easier adjustment to change. It also decreases the likelihood of engaging in self-harm and other maladaptive behaviors.
When appropriate, clinicians can work with the family. As in any family system, we know there are limits to the influence an individual therapist should attempt to exert on the family system.
While much of your work with gender diverse clients in an individual therapy setting centers around processing how the family system impacts their experience and how they can best meet their own needs within that system, it is most appropriate to make referrals when the family unit is to be treated. Emphasize the helpfulness of support groups for family members, as well as the utility of family therapy and benefits of individual therapy for other family members.
You can aid families by pointing to resources they can enlist in further supporting their child. TransYouth and Family Allies maintains a list of resources specifically for parents to support and advocate for gender diverse children. The Trans Youth Equality Foundation provides resources including this book list as well as books oriented toward kids, among other resources and services they provide. This resource provides additional articles around the importance of family acceptance and education regarding trans-related topics.
Therapeutic content with the client
The counseling process with a client with gender-related concerns looks different across clients. There are commonalities, however, that are beneficial to understand and expect within the counseling dynamic. Although each client’s work involves more than one component, anticipating particular elements that may be present in the work can help you to show up well for your client.
First, intentionally show validation and acceptance. Although we can emphasize to families the importance of showing acceptance of a child at home, we have limited control over the way the family operates.
You may provide the only environment in which the client’s pronouns and name are respected, or where their trans identity is validated. Accepting the client with enthusiasm can allow the client to move through this developmental stage of their identity, and of course it's a necessary building block for creating trust and safety in the counseling relationship.
Clients may change their name and/or pronouns as they become more assured or confident in their gender.
Accept these changes in session.
Give the client evidence that you are making the changes alongside them.
Make space for the client to further explore their identity.
Understand gender from the client’s lens, not your own.
Spend time exploring whether your client is experiencing bullying. This could mean bullying in school, or perhaps there are bullies at home. A large part of adolescence involves growing into one's identity as a person, and this process includes a focus on 'fitting in.' Clients may not yet accept differences about themselves.
Adolescents may live in a household where intolerance for the LGBTQ+ community is modeled to them, which may also be present at school. Bullying at home may stem from parents who did not have the ability to explore their identity during their own upbringing. This is then projected onto the child as the child explores their identity.
Therapists can help the client understand how bullying around gender identity has more to do with bullies than it does with the client. Find ways in session to affirm the client’s self-esteem and sense of self. With kids, you might process bullying experiences (or other experiences of intolerance) through play.
Coping with gender dysphoria
Help the client understand and cope with the influence of gender dysphoria, which is the incongruence between the gender the client appears to be on the outside and the gender they know they are innately. The lifelong feeling of not living in the body one belongs in is traumatic. Validating this to the client will help them move through difficult emotions.
Even as a client makes changes to appearance or receives medical gender-affirming care, gender dysphoria can still be present. Process some of the lack of control clients have here. You might also do work grieving the fact that the client’s gender will never match their assigned sex at birth.
Gender-affirming care
Understand the facets of medical gender-affirming care. When a child is pre-pubescent or beginning puberty, medical gender-affirming care involves puberty blockers that prohibit the development of secondary sex characteristics. While puberty blockers, or GnRH analogues, are still being researched, we know that these medications only pause puberty, thus these impacts are reversible in the unlikely event that in the future your child no longer aligns with the gender they begin transitioning to.
When children can consent for themselves, they may choose to explore surgical or hormonal options for gender-affirming care. Some nonbinary individuals may choose to explore medical transition options, seeking an option with which they feel most comfortable. Some trans individuals choose not to pursue medical transition because they do not need it to feel aligned with the gender they identify as.
You can provide psychoeducation related to gender-affirming care when appropriate. Not all gender diverse individuals wish to seek gender-affirming care, so understanding whether this is central for the client is important. For children, this may look less like exploring these topics in session and more like helping families understand trans healthcare.
For adolescents, there is an abundance of misinformation on the internet and in social groups. Misinformation around trans healthcare is no different. Providing accurate information decreases the chance of harm and increases safety for the client, which is helpful even for clients who know that gender-affirming care exists. Process how this knowledge changes the client's view of themselves, their self-esteem, and their self-beliefs.
We encourage those who work with transgender and gender diverse clients to find a doctor local to the are who is equipped to support clients through their transitions. Establishing a relationship with a trusted doctor is an important element to your client's care.
The World Professional Association for Transgender Health (WPATH) provides standards of care for health practitioners to abide by when working with transgender individuals (2022). Explore these standards and choose a doctor that aligns with these standards. Many cities and medical agencies also provide lists of gender-affirming practitioners who are experienced in supporting families through medical and social transitions.
References
Coleman E., Radix, A.E., Bouman, W.P. et al, (2022). Standards of Care for the Health of Transgender and Gender Diverse People, Version 8. International Journal of Transgender Health, 23(1), 1-258. https://www.tandfonline.com/doi/pdf/10.1080/26895269.2022.2100644
Brik, T.,Vrouenraets, L.J.J.J., de Vries, M.C. et al. (2020). Trajectories of Adolescents Treated with Gonadotropin-Releasing Hormone Analogues for Gender Dsyphoria. Archives of Sexual Behavior, 49(1), 2611-2618. https://doi.org/10.1007/s10508-020-01660-8
GLAAD. (n.d.). Transgender Terminology. Retrieved from URL https://glaad.org/reference/trans-terms/
Olson, K. R., Durwood, L., DeMeules, M., & McLaughlin, K. A. (2016). Mental Health of Transgender Children Who Are Supported in Their Identities. Pediatrics, 137(3), e20153223. https://doi.org/10.1542/peds.2015-3223
Malpas, J., Pellicane, M. J., & Glaeser, E. (2022). Family-Based Interventions with Transgender and Gender Expansive Youth: Systematic Review and Best Practice Recommendations. Transgender health, 7(1), 7–29. https://doi.org/10.1089/trgh.2020.0165
Abreu, P. D., Andrade, R. L. P., Maza, I. L. S., Faria, M. G. B. F., Valença, A. B. M., Araújo, E. C., Palha, P. F., Arcêncio, R. A., Pinto, I. C., Ballestero, J. G. A., Almeida, S. A., Nogueira, J. A., & Monroe, A. A. (2022). Support for Mothers, Fathers, or Guardians of Transgender Children and Adolescents: A Systematic Review on the Dynamics of Secondary Social Networks. International journal of environmental research and public health, 19(14), 8652. https://doi.org/10.3390/ijerph19148652
Trans Youth Equality Foundation. (n.d.). Home. Retrieved from URL https://www.transyouthequality.org/
Movement Advancement Project. (n.d.). Advancing Acceptance for Parents. Retrieved from URL https://www.lgbtmap.org/policy-and-issue-analysis/advancing-acceptance-for-parents
Intersex & Genderqueer Recognition Project. (n.d.). For Parents. Retrieved from URLhttp://www.imatyfa.org/parents.html
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