For therapists working with children, youth and families, Transgender, Nonbinary or Gender Expansive children and youth are presenting at increased rates in agencies and independent practice. There are not necessarily “more” young people, but rather, increased safety, visibility and “permission” to come out has led to increased awareness. The more equipped family therapists are to support these young people the better their overall prognosis is regarding family acceptance and positive mental health outcomes.

1.      Listen and accept the wisdom that young people have about their gender

Listening to a child or teen about what they are experiencing regarding gender and accepting this as a clear personal understanding of their identity, is a crucial first step in supporting them in their gender journey. Contrary to critiques or concerns raised, listening does not promote any particular outcome. This is the meaning of “gender health” which is defined as “a child’s opportunity to live in the gender (or expression) that feels most real or comfortable to that child and to express that gender with freedom from restriction, aspersion, or rejection” (Hidalgo et al., 2013, p. 286). This is inherent in a Gender Affirmative Model of care. For children and youth that are supported and discover their identity as more an expression (style, preferences) and not a core, internal sense of self, support has not led to any negative outcomes. This would include things like allowing a “social transition” (clothing, pronoun usage, name changes). No one can “make” anyone Transgender, gay and so on. The only outcome of support are the positive mental health outcomes we know to be true with these children. If someone is supported and comes to a different understanding over time the focus of the support can shift but it is support nonetheless.

2.       Loving and supportive families can struggle with grief, resistance and acceptance

In working with hundreds of families who have gender expansive children and youth in their lives, I have heard time and time again, “I love my child and I will do anything for them” as the caregiver simultaneously continues to misgender (using a name or pronoun that was established at birth) even though the child/youth/young adult has requested explicitly for use of a different name or pronoun.  Other common statements from parents include, “I don’t want to be the one to make a mistake and say yes to allowing transition with medicines or surgery. What if they end up regretting it? They can do what they want when they are 18.” Or parents say, “it would be easier if they were just gay or lesbian but this transgender thing is too far.” I also hear, “this is only because they didn’t have a role model” or “they are too young to know how they feel” or “they were around the cousins too much and think they are a boy/girl because of that” and so on... Some parents need to grieve their assumption or expectation about who they wanted their child to be. Some parents need information and support. Some parents need to be respected for their concerns of safety if indeed they live in communities where their children may experience transphobic violence. While families do often come around to being affirming, it can take time. The crucial intervention for a gender care therapist is to support these feelings while minimizing negative exposure to the child.  It is important to hold the parent with compassion for their fear or frustration that comes up yet continue to help them understand if their responses are increasing vulnerability in their child. In some families it is true that the harm is too great and more active protections for the child need to be implemented. Studies from varied fields focused on care of children and youth clearly show that the better the caregiver is supported, the better the outcome for the child. In some cases, it is true that the level of rejection is concerning enough to intervene particularly if children continue to become increasingly depressed and/or suicidal. Note: the poor mental health outcomes are often not a result of gender itself but rather lack of support. Active acceptance (using requested names/pronouns, allowing/purchasing preferred clothing, respecting wishes of who to tell in extended friends/family, advocating at school or other places the child resides) are the most protective factors for a child’s wellbeing and mental health.

3.   Advocate in your role as a therapist

In gender care, advocacy is a crucial part of a provider’s role. A provider may need to challenge their training or assumption about taking action in a case when indicated. An active stance can be instrumental in preventing poor health outcomes. For example, a rejecting school system may require an active case management role in addition to supporting the mental health of a client coming for gender care focused support. A supportive immediate family who has some rejecting extended family members may need a more direct approach to help parents feel confident to set limits and boundaries with loved ones. A teen who is suicidal over not being considered for any medical steps may need a more direct approach with caregivers. A young adult who has little to no family support may need step by step assistance in doing legal gender marker and name change paperwork. Help families understand what they “did right” rather than what went wrong allows a shift from a deficit model to one that sees it is precisely their love and acceptance that has allowed this child to be their authentic self.

4.  Know your Transgender history to guide intersectional practice

The essence of fully affirming gender care is one where all the intersections meet. The history of who Transgender people are and the ways they have been marginalized, oppressed or elevated all inform us. Knowing for example that Transgender Women of Color are the most vulnerable gives us important information about how to create access for young Trans girls of color in program development and understanding the specific fears that may arise for families with these children. Similarly, in some families it truly may be a safety issue to allow certain expressions in public. Rather than an all or nothing approach maybe that child is given times when expressing gender is safe. Some youth may or may not want to tell family about their identity. Even if your sense is that it would be beneficial for them, it is important to honor a child or teens pace while also understanding their family system is as crucial as getting them active support. Having solid training in mental health offers the clinician an opportunity to understand where mental health and gender health are independent and where they overlap. For example, someone can have depression, trauma, autism, impulsivity and so on, and, also have questions of gender. It should never be a starting point to assume that other issues are the reason a person asserts a Transgender or Nonbinary identity. In some cases, there may be reasons that the gender identity is better understood by other issues but this is much less common. Typically, a person happens to have two concurrent needs. I am in support of mental health support for Transgender/Nonbinary children and youth not because gender itself needs mental health care, but, rather, that is a process to sort feelings, needs and manage others reactions. The stress associated with this is often well supported in a therapy process for both child and caregiver.

To that end, offering a family system, anti-bias, attachment, trauma healing, stage of development, client centered, gender affirming approach is the optimal standard of care. Naturally, we will never be on point with all approaches though openness and humility and following these other guidelines will get us closer.  Here I see the mental health role as its own internal version of interdisciplinary practice. In addition to the mental health role in specific, the standard of practice care model includes a true interdisciplinary approach depending on who is in the child’s system. Some examples of a solid team (as relevant) would include client, family, medicine, eurology, surgery, endocrine, clergy, child welfare, schools, legal, a trans elder or mentor and so on… As in any child/family work bringing all the supports of a child’s system together increases continuity and quality of care.

5. Have transgender, nonbinary and gender expansive leadership and narratives to guide policy

Lived experience is as crucial a variable to shaping policy, program and interventions as is education and training. Care teams function optimally when they have a strong presence of Transgender/Nonbinary leadership and a commitment to listening to patients about what works for them. Advisory boards, mentorship linkage programs and Transgender/Nonbinary staff at all levels are good places to start to ensure that the services and decisions made are truly in the best interest of how the population will be impacted. In child and family settings it is key for caregivers/parents to also see a visible model of a Transgender/Nonbinary adults in all kinds of roles. As the world of gender care grows there are more and more meeting of worlds. In the past, adult gender care and child/family care were thought of as very different needs with different focal points. While this is still true regarding the importance of developmental approaches to care and understanding needs at different stages of life, it is also crucial for gender care providers to understand the value of Trans elders and mentors for children and youth. As we have seen in the beautiful models of older adults with preschool children for example, this connection is curative on both sides. For an elder who has deep wisdom but perhaps had little family support it is also healing to experience a child or youth who is being given a different opportunity to express and identify. Here, we are interrupting cycles of trauma. Trans elders have deep wisdom to share in all kinds of ways. How to navigate a health care visit, how to organize for change, tips on how to apply makeup or cope with distress and so on…Looking at how to shape services and create true equity will offer children and families a truly “trans”formative.