Transgender Children and Youth

THE PREVIOUS CHAPTER FOCUSED ON WHAT MENTAL health professionals can do to provide for the basic needs of families of transgender youth—engage them, provide education to parents, support parents as they work through the range of emotional responses that often emerge in the wake of their child’s disclosure, and connect families to peer supports. This chapter explains the more complex work mental health professionals do with families, with a particular focus on families who struggle with acceptance of their child’s trans identity. As indicated by earlier discussions of the pivotal nature of family acceptance for trans youth, helping families arrive at this place is essential.

The starting point is the premise that almost all parents love their children and want what’s best for them. Almost all parents want their children to grow up to become happy, healthy adults. Mental health professionals should start by assuming best intent, regardless of what the family situation may look like initially. If the professional is not operating with the assumption that everyone wants the same thing—for the transgender child or adolescent to grow up knowing they are loved and that their life has meaning—then this is not the right person to be consulting.

In my experience of supervising and training providers, this is not always the foundational assumption. Sometimes the starting point is the things a transgender young person has told us about their parents—what their parents have said or done to them that felt or was rejecting. Often our immediate response is to protect this young person. This is a totally natural response, given both our role and the compassion that brings us to this work.

At the same time, this response tends to align us with the young person, positioning us on their side as their advocate—even their protector. Being positioned as an advocate is not in and of itself a bad thing; transgender youth need advocates. However, this positioning can mean the rejecting parents become the “bad guys” who have rejected and hurt their child. This can create a dynamic where we align with the young person against their parents. If this becomes our starting point for family work, it will be difficult to engage the parents and establish the alliance needed to facilitate greater acceptance.

The above dynamic has some roots within the initial wave of lesbian and gay community organizing. In the early days of the movement, many individuals were rejected when they came out about their sexual orientation. When these adults (and I was part of this generation) began developing support programs for lesbian and gay youth, parents and families were often viewed as the “enemy.” Creating safe spaces for lesbian and gay youth meant spaces where families were not present. Adult leaders assumed rejection from parents, or at the least viewed these straight parents as unable to adequately understand their lesbian and gay children. Consequently, most programs for lesbian and gay youth focused on providing peer support with other lesbian and gay youth as well as connections to positive lesbian and gay adult role models. This philosophy remained in place within many agencies until fairly recently.

However, as discussed in the previous chapter, recent studies about risk and resilience among LGBT youth point to family acceptance as the critical mediating variable. The data emerging out of the Family Acceptance Project made the risks of family rejection unequivocally clear. Youth growing up in rejecting families were nearly six times as likely to report high levels of depression in young adulthood and more than eight times as likely to have attempted suicide compared to young adults who grew up in accepting families. Youth who grew up in rejecting families were more than three times as likely to be using illegal drugs and more than three times as likely to be at high risk for HIV and other sexually transmitted diseases as young adults (Ryan et al., 2009; Ryan et al., 2010).

Thus, one primary goal of therapy will be to provide specific recommendations about what parents can say or do to communicate acceptance as well as to educate parents about what they say or do that communicates rejection.

Beyond understanding the distinctions between basic concepts about sex, gender identity, gender expression, and sexual orientation, the information most frequently needed by families is what we have learned from the Family Acceptance Project about risk factors and positive outcomes for transgender adolescents. (https://familyproject.sfsu.ed

The need for parents to communicate acceptance is essential for their children to become healthy, happy, productive young adults. Therapists must discuss the specific parental behaviors that facilitate acceptance or rejection and help parents pay attention to the messages or behaviors they are communicating to their children.

The verbal messages or actions listed below disrespect the transgender young person’s sense of self. These actions communicate the message that there is something bad or wrong about the young person. They signal that who they are is not OK. Messages like this are internalized by the young person, often leading to depression and feelings of rejection and contributing to high risk factors among transgender youth. These message and actions are particularly damaging when they come from parents but are also problematic when they come from other important adults, such as grandparents, aunts, or uncles.

Accepting parents set boundaries that respect is required from everyone in the household or family. Not only do accepting parents themselves not engage in disrespectful comments or behaviors, but they also ensure that other family members do not act in these ways toward the transgender young person. If other family members do not feel it is OK for the youth to be transgender or to dress a certain way, accepting parents make it clear that while these adults can believe whatever they want personally, their words and actions must be respectful.

Verbal messages and behaviors that have been identified as communicating rejection to transgender youth included the following:

As indicated in Chapter 6, nearly three quarters of trans youth experience verbal abuse from their families. More than one quarter report having been slapped, beaten, or hit very hard, and 13% to 20% report having been punched, kicked, or pushed very hard (Grossman & D’Augelli, 2007). Young trans women (typically perceived early on as gender-variant boys) are at highest risk for physical abuse within their homes (Koken et al., 2009).

MAKING FUN OF A CHILD’S AFFIRMED GENDER OR NONBINARY IDENTITY; DEMEANING TRANSGENDER PEOPLE BY MAKING JOKES ABOUT THEM OR PUTTING THEM DOWN.

When parents or other family members ridicule a trans young person or make fun of their gender identity or expression, it contributes to the trans young person feeling “less than.” Similarly, when parents or other family members make demeaning remarks about transgender people in general, the trans youth internalizes these comments as a message about their own self-worth as well because they know they are part of this group.

Communicating any shaming messages diminishes the young person’s sense of self and makes them feel less than human. Hearing the message that your parents or other important adults are ashamed of you signals that who you are is not good or worthwhile. Young people internalize this sense of shame, which puts them at high risk for self-harming behaviors.

This essentially constitutes pressuring a child to be other than who they are and creates a situation in which the young person feels compelled to develop and maintain a false self in order to obtain their family’s acceptance and approval. Children internalize this requirement to be other than who they are and take in a message that says, “If my parents only accept or love me when I am presenting a false self, this means my parents do not love or accept the real me.”

EXCLUDING A CHILD FROM FAMILY ACTIVITIES OR EVENTS BECAUSE OF THEIR GENDER IDENTITY OR EXPRESSION.

This type of exclusion is punitive. It communicates that the young person is not wanted or welcome, reinforcing the message that who they are is not acceptable.

REJECTING A CHILD’S LGBTQ FRIENDS; NOT ALLOWING THE YOUNG PERSON TO SPEND TIME WITH THEIR FRIENDS; DENYING ACCESS TO TRANS-AFFIRMING YOUTH GROUPS, EVENTS, OR PROGRAMS.

Rejecting a child’s friends when the child knows they are like their friends communicates rejection of the child as well. In addition, these actions isolate the young person, making them feel as if they are the only one like this. The isolation exacerbates the shame the young person has internalized.

BLAMING A CHILD WHEN SOMEONE TEASES OR BULLIES THEM FOR “NON-NORMATIVE” GENDER EXPRESSION OR NOT BEING A “REAL” GIRL OR BOY.

One adolescent I worked with was being bullied at school. When the young man disclosed this to his father, his father responded, “If you dressed like a real man, you wouldn’t get pushed around.” When parents blame their children for being bullied, it sends a message that the young person deserves the harassment because of who they are—in other words, who you are is not OK.

One 13-year-old trans boy’s father periodically told him, “You are not a boy; you were my daughter when you were born and you will always be my daughter.” This kind of parental denial challenges the adolescent’s reality as well as sending the message that the parent will never accept the young person’s understanding of themselves.

NOT USING THE YOUNG PERSON’S AFFIRMED NAME OR PRONOUNS, OR EXCUSING OTHERS WHO DON’T USE THE CHILD’S AFFIRMED NAME OR PRONOUNS.

As challenging of an adjustment as this generally is for parents, refusing to use the young person’s affirmed name and pronouns communicates disrespect for their identity. This is another way of dismissing or denying the young person’s sense of self. When Cheryl’s parents kept using her birth-assigned name, what she heard was, “We do not see you as a girl. We do not believe you really are a girl.” When parents continue to use the birth name and pronouns, the young person often begins to feel hopeless. They begin to assume other people will never see them in their affirmed gender; they will never be able to be their true self; others will never see them for who they really are. This contributes to feelings of invisibility and, concomitantly, isolation.

BEING UPSET (ANGRY, SAD, CRYING, DISAPPOINTED, AFRAID) ABOUT A CHILD’S TRANS IDENTITY/AFFIRMED GENDER TOO OFTEN WHEN THEY ARE PRESENT.

This is sometimes challenging for parents, depending on where they are in their own emotional process. Julie, as 15-year-old trans woman, told me, “My mom is always crying about my transition. I’ll come in the living room and find her looking at one of my childhood pictures and crying. It makes me feel bad. I don’t want to make my mom feel sad all the time.” When trans youth are exposed to intense parental emotions like this, they tend to internalize the sense that they are a/the problem, that they upset their parents and make their parents feel bad, and that their parents are disappointed in them. All of these messages contribute to low self-esteem and low self-worth—factors that can contribute to increased risk for trans youth. It is critical to create spaces where parents can process their emotional reactions to their child’s disclosure and/or transition apart from their child. This can be in a session with you, with the parent’s personal therapist if they have one, or within a support group for parents of trans or LGBTQ youth.

This is a more subtle message of rejection, but when youth come out as transgender and parents ignore the information and never bring the topic up again, this sends the message that being transgender (who they are) is something that is too bad, sinful, or wrong to talk about. It can also communicate the message that parents do not think this is important to discuss, which says to the young person, “You are not important enough for me to be interested in you, the things that are important to you, or who you are.”

Secrets tend to be things we are ashamed about. When parents insist that their child keep their affirmed gender (who they are) secret, it sends the message that there is something shameful about them.

TELLING A CHILD THAT WHO THEY ARE IS A SIN OR THAT GOD WILL PUNISH THEM FOR BEING TRANS.

Regardless of a parent’s religious beliefs, this message clearly communicates to a young person that who they are is not acceptable.

As opposed to sending messages that communicate rejection, there are many ways parents can communicate their love, acceptance, and support. This is true even when parents may still be struggling with their own beliefs or emotions. Verbal messages and behaviors that have been identified as communicating acceptance to transgender youth include the following:

INITIATING CONVERSATIONS ABOUT A CHILD’S GENDER IDENTITY/EXPRESSION; EXPRESSING INTEREST IN THEIR UNDERSTANDING OF THEMSELVES; KEEPING THE LINES OF COMMUNICATION OPEN, EVEN AFTER THE CHILD TRANSITIONS; NOT ASSUMING THERE’S NOTHING MORE TO TALK ABOUT NOW.

When parents or other adults initiate conversations about the child’s gender identity or expression and express interest in hearing more about the young person’s identity, this communicates the child’s importance to the adults in their life. This kind of parent-initiated check-in is important even after trans youth have transitioned and seem to be doing well.

ESTABLISHING A “ZERO-TOLERANCE” POLICY FOR DISRESPECT, RIDICULE, TEASING, OR PRESSURE TO CONFORM TO NORMATIVE GENDER EXPECTATIONS WITHIN THE FAMILY; INSISTING ON RESPECT FOR A CHILD FROM EVERYONE IN THE FAMILY’S LIFE (THEY MAY NOT AGREE, BUT THEY MUST TREAT THE CHILD AS A HUMAN BEING WORTHY OF RESPECT AND DIGNITY).

It is essential to create a supportive home environment. Insisting that others respect the child, even if they do not agree that being trans is OK, is critical. When parents stand up for their child and do not allow others (including siblings or extended family members) to tease their child or advocate on their behalf if someone harasses them, they send a clear message of support. Demonstrating that a parent “has their child’s back” is an assurance of love. The message the young person will hear is, “I can count on you to be there for me even if I’m trans.”

VERBALIZING LOVE AND SUPPORT FOR A CHILD, INCLUDING THEIR GENDER IDENTITY/EXPRESSION.

It is essential for parents to verbally assure their child that they love them—even when they do not believe their child is transgender or when they feel the child’s transgender identity is something they cannot accept. When parents struggle with the news that their child is trans, the parents may withdraw and become less communicative or affectionate. This sends a message that the parents are not comfortable or not OK with who the child is.

INTRODUCING A CHILD TO POSITIVE TRANSGENDER ROLE MODELS; TAKING A CHILD TO TRANS-IDENTIFIED OR TRANS-AFFIRMING YOUTH GROUPS AND ACTIVITIES.

Helping children find positive adult transgender role models and allowing them to participate in trans-affirming activities and support groups lets teens know that they are accepted and supported. Meeting positive adult role models reinforces a message that the child’s future is hopeful and positive.

IF A CHILD HAS TRANS AND/OR LGBTQ FRIENDS, SUPPORTING THESE FRIENDSHIPS; IF A TEEN IS DATING SOMEONE, INVITING THAT PERSON INTO YOUR HOME;

When parents welcome their children’s friends and dating partners into their homes, their children feel supported by their parents. Embracing their friends or partners also embraces them.

HOLD LOVE TO BE THE MOST IMPORTANT THING—MORE IMPORTANT THAN SOCIAL NORMS, FIRMLY HELD BELIEFS AND TRADITIONS, OR WHAT OTHER PEOPLE MIGHT THINK.

Holding love as the “most important thing” is an important aspect of communicating acceptance. When parents do this, they send the message that love for their child and their commitment to their child’s well-being is more important than social or cultural norms, more important than firmly held beliefs, more important than what others may think. In conjunction with this, when parents “stretch” beyond their comfort zone to support their child’s identity—even when it makes the parents uncomfortable—they communicate acceptance.

FOCUSING ON A CHILD’S HAPPINESS; SUPPORTING A CHILD—VERBALLY AND THROUGH THESE POSITIVE PARENTING PRACTICES—EVEN IF IT SOMETIMES MAKES YOU UNCOMFORTABLE.

These practices are challenging when parents are upset or uncomfortable with their child’s trans identity or varying gender expression. At the same time, being a parent stretches all of us. Whether our children are transgender or not, there will be times when parenting means doing things that may not feel comfortable to us as parents. The style of parenting one child needs may not be our natural way of parenting, and yet, being present for this child and supporting them means we have to be willing sometimes to act in ways that are not the most comfortable for us. This is part of being a parent. When mental health professionals help parents to broaden this task beyond the specific needs of their transgender child and to see stretching beyond their comfort zone as inherent to being a parent, it can make it easier for them to communicate unconditional love and acceptance for their transgender child even when there may be ways that the parent is still not quite OK with their child’s affirmed identity.

BELIEVING AND REGULARLY COMMUNICATING FAITH IN A CHILD’S ABILITY TO HAVE A HAPPY, HEALTHY, MEANINGFUL ADULT LIFE—A LIFE WITH THE POSSIBILITY OF FINDING LOVE, COMMITMENT, MEANINGFUL WORK, AND FAMILY.

Media images of transgender people are often negative. Consequently, many parents worry about their child’s future and safety, especially early on. Yet, it is critical for parents to communicate faith in their child’s ability to have a happy and fulfilling future as a trans adult—life with professional success, friends, and the possibility of finding love ad commitment and creating a family of their own. Enabling parents and other family members to navigate their own fears, questions, loss, or anger in order to be able to send a consistent message of love and support lies at the core of a mental health professional’s work with families.

The following vignette illustrates some ways of the reasons why parents must make this effort:

Sixteen-year-old Toshina and her parents came to see me about one year after she disclosed that she was a transgender woman. Since that point, her gender expression had become more feminine, though she had not yet fully transitioned at school. About to finish her sophomore year, Toshina was pushing her parents to let her start school in the fall as a girl. She also wanted to begin taking estrogen before the end of the year.

Her parents, Jerome and Kim, had an uneasy truce with her trans identity. They were clear that they loved her and were not entirely rejecting of her being trans-identified, but they still used her male name and pronouns most of the time. They were OK with Toshina’s clothes becoming a bit more feminine, but they drew the line at Toshina leaving the house dressed like her best female friends. They knew she used “Toshina” with her close friends and that she had a boyfriend, but they were not ready for her to attend school as “Toshina.”

Neither Kim nor Jerome told anyone in their extended family about Toshina’s affirmed gender, including Kim’s mother, with whom they were very close. Both parents had been raised in a Black Baptist church. While their personal religious beliefs had shifted since then, they worried about how relatives would respond if they allowed Toshina to transition.

About two months into our work, Toshina brought up a family wedding scheduled later that summer. Several of her cousins were bringing their girlfriends or boyfriends, and she wanted to invite her boyfriend, Marcus, too. She wanted to wear a dress like her girl cousins and wanted her relatives to know she was his girlfriend. The way Toshina’s face lit up made clear how important this was to her. As Toshina and I discussed what this would mean for her, she talked about not wanting to pretend anymore; she wanted to be able to be real with her cousins. In part, she did want to show Marcus off just as her cousins would be showing off their girlfriends or boyfriends. However, she wanted her cousins and aunts and uncles to meet Marcus authentically—not assuming they were friends, but seeing Marcus as her boyfriend and seeing Toshina as she was, his girlfriend.

Kim and Jerome were hesitant. They weren’t sure they were ready to be open about Toshina’s affirmed gender with their parents and siblings. They thought they might be willing to tell other family members about Toshina coming out, but they worried that Toshina attending the wedding as a girl would be “too much” for some of their family members. The hard part was that their reluctance to allow her to be visible in her real self (as a young woman) made Toshina feel that her parents did not truly accept her for who she was or that they were embarrassed about her.

After my initial assessment process with Toshina and her parents, much of my work was with Jerome and Kim, given their reluctance about Toshina fully being out in the world. Toshina was clear about her identity and eager to transition. She was impatient and sometimes angry with her parents’ hesitation, feeling as if one year was long enough for them to get used to her being their daughter.

In the course of conversations with the parents, we began to discuss the importance of family acceptance and support for Toshina. We discussed the risk factors if she did not feel accepted and supported, particularly by her parents. It was clear that Jerome and Kim loved their daughter very much. There was no question that they wanted her to grow up into a happy and healthy young adult. As we looked at the ways Kim and Jerome could communicate acceptance, we focused on three in particular:

•Hold love as the most important thing; make love more important than social norms or what other people might think.

The parents and I discussed the ways these practices are an important aspect of parenting, whether or not your child is transgender. We acknowledged, and even laughed about, the fact that children rarely grow up to be exactly the way we imagined they would—that each child, like each human being, is unique and sometimes requires different ways of parenting, including approaches that might not be natural or easy for us.

We discussed the importance of using Toshina’s affirmed name and pronouns and how this reflected their acceptance of who she was—how using her affirmed name communicated that they saw her for who she really was, their daughter, Toshina. I suggested that they to try this at home more often, even if they were not ready to do so in public. Over time, Toshina reported that Jerome and Kim were calling her Toshina at home more often.

Kim initiated a conversation about Toshina’s coming out with her mother, who was more supportive than Kim imagined she would be. At one point, the grandmother joined us for a family session because she wanted to understand Toshina better.

By late July, Jerome and Kim told Toshina she could invite Marcus to the wedding. They were still not entirely convinced this was the “right” thing to do, but they were willing to share Toshina’s affirmed gender with the extended family.

The week after the wedding, Toshina was beaming when she came to see me. She talked nonstop for nearly 20 minutes about how amazing it was to be there as Toshina and have her cousins see her as Marcus’s girlfriend. “I was able to be me,” she said, “the real me, finally.” It was clear that the wedding was a significant moment both for Toshina and her parents. Despite some lingering reservations, Kim and Jerome stretched beyond their personal comfort zone to make communicating their love and support to Toshina the most important thing in that moment.

Sharing findings about the high risks for young people growing up in rejecting families highlights just what is at stake and can enable parents to see the risks of maintaining behaviors that communicate rejection to their children. When parents know what parental practices increase greater positive young adult outcomes for their children, they are empowered to make choices that improve their child’s quality of life. Rather than simply telling parents that they need to be accepting, therapists need to help parents see what acceptance and support look like in action.

Each positive parental behavior increases the young person’s sense of acceptance, decreases young adult risk factors, and promotes greater positive outcomes for trans youth.

The vignette about Toshina and her parents illustrates how these findings can enable therapists to identify and work from common ground. Few parents want to see their children engaged in illegal drug use or alcohol abuse. Few parents want their children to experience debilitating depression or anxiety. Few parents want their children to feel so hopeless they attempt suicide. I have yet to meet a parent who wanted to bury a child. This sounds harsh, but it points to the fact that it is almost always possible to arrive at some piece of common ground in therapeutic work with families.

Almost all parents love their children and want the best for them. Even parents who deny that their child’s gender identity could vary from the sex assigned at birth, even parents who are uncomfortable with their children coming out as trans, and even parents who believe being transgender is “wrong” generally still want their children to become happy, healthy, and alive young adults. In identifying this common ground of loving their children and wanting the best for them, therapists and parents can often reach beneath what might look like rejection and touch the hopes every parent holds for their children.

Almost every social work or counseling textbook tells students, “Start where the client is.” Yet, it is all too easy for therapists to jump ahead of the family, or individual family members, in an attempt to get them to where we believe they need to be—in full support of their transgender child. While this is the end goal, therapists need to remember that the starting point in therapeutic work is wherever this particular family is today. We have discussed the urgency and potential risk factors, especially for transgender adolescents. This means we do want to move the family toward acceptance, and as quickly as possible. At the same time, families will make this journey with us only if we start where they are right now.

Families typically get “stuck” at one of two points: accepting the child’s transgender identity or reaching consensus about transition steps. Early on, families may struggle to believe that, or disagree about whether, their child actually is transgender. Further into the process, family members may have different opinions about whether or when the young person should socially transition or begin some aspect of a medical transition, such as hormone blockers or feminizing or masculinizing hormone therapy.

Starting where the family is means obtaining a full, detailed understanding of where the family, or individual family member, is stuck or in disagreement. In these moments, I ask myself: What barrier is currently keeping them from accepting their child? What stands in the way of their ability to fully support their child? What might enable greater acceptance from the family?

In my interactions with the parents (while I refer to parents in this section, the points equally apply to grandparents and other family members), I begin by asking them to tell me more about their concerns or objections. My goal is to understand in detail (rather than superficially) as much as possible about the parent’s concerns. If they tell me, “I’m worried she won’t have a good life,” I don’t let the conversation stop here. I draw them out further so I can really understand and appreciate what this specific parent worries about. I might have a hunch, but it is only a hunch until they tell me more. In the following example, the father’s 15-year-old son, John, has recently come out as a transgender girl.

I might continue exploring the father’s concerns with questions such as: “What if John did feel differently at 25 years old? What then? What do you imagine that might be like for John? For you? For other people in John’s life? What do you worry might happen if John did change his mind later on? What would make you worry about this possibility?”

At this point, I do not attempt to dissuade the father from being concerned about John changing his mind. Even though I know most transgender people who come out in adolescence continue to identify as trans in adulthood, my goal in the moment is to fully hear the father’s concerns or objections, to understand what this father in particular worries about, to understand clearly what worries the father in terms of who John is and how the father sees John’s strengths or challenges.

Other directions to explore might include understanding the father and his history better. Are there aspects of the father’s history that contribute to his concern for John? I might ask the father, “Have you known other people who felt one way as a teenager but felt differently as adults? Was there anything you felt strongly about or believed as a teenager that shifted in your adult life?” These questions allow me to learn more about the father’s perspective and what experiences have shaped his view. A parent’s concern for their child can be rooted in their own life narrative—or that of a close family member, such as a sibling. Getting this history out on the table can help us separate the father’s earlier experiences from John’s current disclosure of being transgender. It can sometimes help us clarify whether the father’s worries are really about John or more reflective of the father’s history and perhaps not true for John.

Coupled with reaching for a detailed understanding of the parent’s concerns, it is essential for therapists to actively listen to the family’s responses and validate their concerns. This is reflected in the previous example when the counselor acknowledges that identity exploration is often part of being a teenager. Rather than counter or debate whether this assumption is always true, I validate this as a fairly normative adolescent developmental task. The important piece right now is for the parents to believe the clinician truly hears and understands their feelings and concerns.

This process cannot be rushed. At this stage in the work with a stuck or rejecting family, you cannot challenge, object, debate, or argue with a family member very much. The goal is to build an alliance with the family (or family member), and this is only possible when they trust that you understand where they are in this moment. This means exploring how they view their parental role, how they understand what this particular child needs from them, what their hopes and dreams are for their child, and what things they worry about in terms of their child identifying as transgender or taking the next step in a gender transition.

If the parents are angry, stay present in their anger—for as long as it takes to get through it. If the parents are afraid, stay present in their fear—for as long as it takes to navigate and/or resolve it. As opposed to shying away from their feelings, lean into them and encourage them to express these feelings fully. We do this by drawing them out, by asking questions that demonstrate our interest in what is important to them and our willingness to listen and understand. We communicate our ability to appreciate their point of view. We acknowledge how the immediate situation would make them upset, fearful, and so forth. We acknowledge and validate the things the parent is angry or worried about.

In many ways, this parallels work with mandated clients. You cannot really begin the therapeutic process or engage treatment goals with most mandated clients until you fully engage the client’s anger and resistance about having to be there. The starting point is the client’s resentment around treatment not being their choice. You validate that being in treatment involuntarily would make many people angry. You acknowledge that their anger in this situation is understandable. You might even acknowledge that you, too, would feel angry about being required to attend treatment if you didn’t want, or feel you needed, counseling.

The starting point to effectively engage involuntary clients is always listening to and validating their resistance, anger, and resentment. You cannot move beyond this initial work until the client experiences the sense that they have been heard, that you “get” why they are upset, and that you can appreciate that feeing upset is a reasonable response to their situation. It is the experience of being heard that creates a small opening for movement in a new direction. In the same way, when rejecting parents feel fully heard, you may discover a window of willingness to hear a different idea, or think outside the box, or explore the possibility of some middle ground between rejection and acceptance. The following vignette illustrates this process.

Mr. Jamison was referred by another therapist. He and his wife were separated and lived in two different cities. Their only child (born female) was a freshman at an out-of-state college. About six months prior, the young person, now going by Stephen, had come out to his parents as a transgender man. Both parents were surprised by this and reported that their child’s gender expression had always been fairly normative. They had never seen any indications of a more masculine gender identity before Stephen’s announcement.

The father had been talking with his therapist about Stephen’s disclosure and had reached a place of relative acceptance, though he still had many questions. His wife, on the other hand, did not believe that Stephen was transgender. She thought this was just a phase and was very upset about Stephen’s disclosure.

The impetus for Mr. Jamison reaching out to me was that Stephen had recently told his parents that he wanted to begin taking testosterone. Mrs. Jamison was extremely upset about this and thought a parent should do anything they could to prevent Stephen from beginning hormone therapy. Mr. Jamison was not particularly comfortable with Stephen starting hormones but also thought there wasn’t much the parents could do to stop it, since Stephen was 19 years old. Mr. Jamison called and asked if I could do a family session with the three of them to help them work through their different ideas.

Our appointment began with Stephen announcing that it was not his choice to be there that day. He did not need therapy. It was his parents who needed it. He had only come as a courtesy to his parents because it seemed important to them.

As I gathered their family history and explored Stephen’s recent disclosure, Mrs. Jamison became increasingly angry. While she did not believe Stephen really was a man, what she was most angry about was learning about Stephen’s disclosure through Facebook. “She didn’t even have the courtesy to tell me directly! I had to learn through her Facebook post to everyone. How could she not talk to me before she told all of her friends? It’s just rude not to talk with me first.” Mrs. Jamison was clearly enraged about this and kept returning to the point.

Stephen was clear that he did not want to talk about how he had come out to her. The only thing he wanted to talk about was the fact that he wanted to begin taking testosterone, and that he was going to begin whether his parents supported this or not—though he indicated he would rather have their support.

Mr. Jamison took a conciliatory role, trying to make peace between his wife and young adult child. At some point when it seemed Mrs. Jamison was not able to move beyond how Stephen disclosed, I suggested that Stephen step out for a while and allow me to meet with his parents alone.

After Stephen left, I began to more directly engage Mrs. Jamison around her anger. I encouraged her to tell me more about what in particular upset her about Stephen coming out on Facebook and not speaking to her beforehand. She responded, “How dare she treat me like this? She embarrassed me in front of my friends! How could she not talk to me about this first? I shouldn’t be the last to find out something like this!”

I worked to listen, understand, and validate her anger. As we made space for her anger, we began to identify some of the emotions beneath her anger—feeling hurt, left out, unimportant, not needed anymore. I validated these feelings as well. I let her know I could appreciate her being upset and angry that Stephen hadn’t spoken to her first, that I could see how this would make her feel left out of Stephen’s life and, thus, unimportant. I acknowledged that I could see this was hurtful.

In terms of my own feelings, after about the first five minutes of this conversation, part of me became impatient with Mrs. Jamison’s inability to move beyond the Facebook disclosure. From my point of view, this was done and over and there was nothing we could do to change how Stephen disclosed being transgender. Another part of me felt annoyed that this seemed to be all about her, with little acknowledgment of any feelings Stephen might have.

I knew this was a double-session assessment and that I would not be working with the family in an ongoing way. I was concerned about how urgently Stephen wanted to begin testosterone. I also had concerns about the degree of depression he seemed to be struggling with. I was concerned about enabling Mrs. Jamison to be prepared for this next step in Stephen’s transition, even if she was not ready to accept it.

Mrs. Jamison was also enraged that there was an LGBT health center in the city where Stephen attended college. Stephen had told them he’d already had his first appointment there. He was going back next week to review his bloodwork, and if everything was good, he could start T that day. Mrs. Jamison was outraged about Stephen starting this quickly. “Isn’t this unethical?” she asked. “How can any ethical medical doctor allow someone as young as 19 years to begin taking testosterone just like that? How can they even know whether she really is transgender that quickly?”

I initially attempted to explain the informed consent model, but I quickly realized this was positioning me as defending this approach in opposition to Mrs. Jamison’s stance about it. I stepped back from explaining the model and refocused on acknowledging her feelings about it. I indicated that I could appreciate her concerns and understood her being upset that Stephen would be allowed to proceed with hormone therapy this quickly.

Despite the critical importance of these conversations, I was conscious of our limited time and began to shift our conversation away from her distress to talk about what Stephen needed from them now. I had to interrupt Mrs. Jamison and say that I could see she was still upset, yet I was also aware of how limited our time was and that I felt we needed to talk about next steps. My sense was that Mrs. Jamison would have happily continued to rage, but I also felt she had experienced enough acknowledgment to allow me to shift the focus.

As I interrupted here to shift the topic, I continued to acknowledge how important it was for her to have a place to express her anger. I encouraged her to follow up by talking with her own individual therapist about these feelings.

We were able to shift topics and discuss the likelihood that Stephen would begin testosterone shortly. We spent time addressing the effects and possible risks of hormone therapy. From there, I shifted to what Stephen needed from them most and introduced the Family Acceptance Project material about the importance of family acceptance. Over the next few minutes, we acknowledged that the parents were not entirely on board with Stephen beginning T. Still, it was essential that they communicate their unconditional love and support for him, especially given his depression. Mrs. Jamison struggled with this. She did not want Stephen to think she was OK with all this. We explored some ways she could acknowledge that she did still have many questions and concerns. She said she would continue to work with her therapist about these. She was able to then affirm that she loved Stephen unconditionally and that he would always have her support.

Throughout this session, it was essential for me to manage my own emotional reactions so that I could be patient and stay present with Mrs. Jamison’s anger. It was critical for me to validate her objections and feelings about Stephen coming out on Facebook without talking with his mother beforehand. Without acknowledging and validating her rage, we would never have been able to address the importance of the parents’ expressing their unconditional love to Stephen.

As addressed at the beginning of this chapter, sometimes our commitment to being an advocate for the transgender young person can interfere with building an alliance with their parents. It was important not to view Mrs. Jamison as the “bad guy” simply because she was stuck in her anger and rejection. If we want to facilitate a shift within the family, we cannot let our own emotional reactions—such as my impatience with her repeated return to the Facebook post—get in the way of building an effective alliance. When an alliance does not seem possible, at the very least we need to establish some connection with the parents. This is only possible as I come to deeply understand and appreciate the immediate situation through the eyes of the parents—not just through the eyes of the transgender young person.

There have been a few moments when I’ve needed to lean in quickly with parents and could not spend as much time building as strong of a connection as I normally would want to. These were situations when the risk seemed high—when the young person was acutely depressed and/or actively suicidal. In these situations, I needed the parents to set aside their objections more quickly and express their love for their child in order to keep their child alive. I still navigate this shift in conjunction with presenting the risks from the FAP. However, I convey a greater sense of urgency and lean into the risk factors alongside their role as parents rather than reaching for a well-formed alliance with them. As I lean in to press for change toward expressing greater support for their child, I might say something like this:

I realize you still have a lot of feelings about James coming out as a transgender young woman. I know this is something you believe is wrong, and I respect the strength of your convictions.

At the same time, I am aware—and I know you are as well—that James is extremely depressed. He acknowledged that he is thinking about suicide frequently and sometimes feels this is the only way out.

I know how much you love your child and want the best for him. I know how seriously you take your responsibility as his parent.

Given that, and what we know now about the risks for young people when they feel rejected by their families, I am wondering if there is any way we can hold your questions and concerns, your conviction that being transgender is wrong, in one hand and yet at the same time find a way to reassure James that you love him unconditionally. [In some situations with religious families, I might be bold enough to say, “that you love him unconditionally just as God, his Creator, does.] I wonder if there is a way to reassure James that you love him as he is, whether he is transgender or not—even if your beliefs have not changed. I wonder if there is any way—without changing what you believe—to hold your love for James, and keeping him safe and alive, as the most important thing in this moment.

I know we have a lot more to talk about in terms of how to work all this out—the differences between what you believe and James believing he is a girl. And I realize I am asking you to do something that may be difficult for you to juggle. But in this moment, what I want to most ensure is that James will be here so we can do this work together, so we can find a way through this. And what he needs to know most right now is that you, as his parents, love him unconditionally—whether he is transgender or not. He needs to know his life has value to you.

I am aware that what I have said above is intense. I only lean into these words when the situation with a young person’s life seems truly at a crisis point and I need the parents to engage in an accepting way regardless of their beliefs. You’ll notice that I am clear I am not trying to change their beliefs. While people’s beliefs can shift over time, pushing them to change what they think or feel rarely works in the moment. What I am seeking here is a short-term “fix,” not a long-term solution. The work of finding a way for the family to navigate their differences will need to continue after the crisis has passed.

The clinical focus while exploring and validating the parents’ struggles has been to reflect on what may be at the core of their conflict and what the family may need to move toward greater acceptance. By starting where the family is at that moment, therapists gain a more thorough understanding of the parents’ perspective. They have a better sense of what their specific concerns or objections are, thus enabling them to more accurately assess where parents are stuck. This sets the stage to develop effective interventions that align with where the family is in the moment.

At this point, I return to my original questions in light of the information I’ve learned about the nuances of the family’s struggles and/or conflicts. What barrier keeps them from accepting (or communicating their acceptance) their child? What stands in the way of fully supporting their child? What might enable greater acceptance from the family?

There are several barriers that can prevent acceptance within families of trans youth. Often these barriers fall into one of two categories. In the first scenario, the barrier involves a knowledge gap; there is some area in which the family needs more information, and it is this lack of understanding that inhibits greater acceptance. In the second scenario, the barrier typically lies within the emotional realm. There is some emotional conflict that blocks greater acceptance, or some buried emotion that needs to surface before it can be resolved. Again, the goal of the earlier focus on deeply exploring the parents’ perception of the immediate situation was to gather enough information to assess the nature of the barrier at this stage in the process. Knowing what has them stuck enables you to develop an intervention in line with the family’s needs.

PARENTS: WHILE READING THE FOLLOWING MATERIAL, THINK ABOUT YOUR OWN NEEDS AND RESPONSES TO YOUR CHILD.

Some families get stuck because they need more information about transgender issues. As a therapist assesses where they are stuck, the knowledge gap becomes clear. For example, it may become apparent that the parents still struggle with the difference between concepts of sex, gender identity, gender expression, and sexual orientation.

Janelle came in to our appointment upset and told me her mom had “done it again.” “She went off again on this long thing about if I liked girls, why did I have to transition? Couldn’t I just be a boy that liked girls like most boys do? What was the big difference? She just doesn’t get it. I’m not a boy. I’m a girl—a girl who likes other girls. When she goes off like this, I feel like she still doesn’t accept me as a girl.”

I raised this with Janelle’s mother when she and I met during the second part of the appointment. This was not the first time the mom and I had discussed the differences between biological sex and gender identity, but what became clear in this conversation was that the mother was conflating gender identity, gender expression, and sexual orientation. Janelle’s mother did not fully understand that gender identity and sexual orientation are two different aspects of who we are—that we all have both a gender identity and a sexual orientation.

The mom thought if Janelle liked girls, it would have been a lot easier to “just stay a boy.” The mom didn’t understand that when Janelle imagined being close with her girlfriend, she envisioned herself as a girl too. As we worked through these concepts, the mother gained a clearer understanding of the differences between her daughter’s gender identity as a young woman and her sexual orientation as a woman attracted to other women.

Other times, it becomes clear that parents need more information about transgender children or adolescents in particular. They may have some knowledge about trans adults from the media but question how a young person could know they are transgender. Sometimes the parents appear stuck in fear, but what emerges is that the need for specific information about puberty blockers (or another aspect of transition) is more important than space to express their fear. In this scenario, the barrier is not so much an emotional one as it is the lack of information. Once the parents gain more knowledge about hormone blockers, their fear diminishes. This illustrates the importance of closely assessing whether the barrier is about needing information as opposed to being more emotional in nature. A struggle that initially seems like an emotional need may turn out to be more rooted in inadequate information about a particular aspect of gender transition.

One other area of education that is helpful for many parents involves grasping the differences between what the parents intend and believe they are saying and what their children actually hear. Functioning as a family translator in this sense and helping parents understand how their transgender child hears certain statements is critical. For example, many parents struggle in making the adjustment to consistently using their child’s affirmed name and pronouns. From the parents’ perspective, when they forget and use the child’s birth-assigned name or pronouns, they generally believe they are doing the best they can. They want their children to understand how difficult this is for them. They want their children to be more patient with them. They don’t understand why their children get so upset when they just “make a mistake.”

The missing link in this situation is that the parents are generally unaware of what their child is actually hearing when they “mess up” and use the old name or pronouns. While the parents perceive this as a “mistake” (and they are usually sorry for making this mistake), the trans youth hears their parent saying to them, “You are not who you think you are. I do not believe you are who you understand yourself to be. Who you are is not OK or real.” This is a critical piece of information for parents, because it directly contributes to whether their child feels accepted or rejected.

PARENTS: DO YOU RECOGNIZE YOURSELF IN ANY OF THESE STATEMENTS? IT’S OK IF YOU DO! THIS IS ALL A LEARNING PROCESS AND A JOURNEY.

When a clinical assessment of the barrier reflects insufficient knowledge, two strategies can enhance the usefulness of the information that is shared. First, it is helpful to ask for permission before sharing new information with parents and family. For example, you could say, “Would it be okay with you if I shared some of what we’re learning about transgender teenagers?” or “Would it be all right if I shared some of how we understand the differences between sex, gender identity, and gender expression?”

Asking permission typically decreases defensiveness and thus facilitates greater openness to processing the new information. Obtaining permission tends to create greater buy-in from parents to continue the discussion with you. Asking permission also levels the power differential between the parents/client and you as the professional/expert a bit and reinforces the family’s self-determination. It reinforces their competence in receiving and making decisions about new information as opposed to being told what they should believe or do by an outsider. With families who are entrenched in their rejection, these factors can be critical in attempting to create an opening for positive change. With families from more conservative religious contexts, there may be an inherent wariness that an outside mental health professional (whose education is secular and not faith or scripture based) will attempt to change the family’s beliefs. Therapeutic effectiveness rests on finding a way to navigate this initial distrust and build an alliance anyway.

Another aspect that can determine effectiveness with families within conservative religious traditions relates to how the “problem” is framed. Some of these parents communicate rejection toward their child because the concept of transgender identity conflicts with their religious beliefs. In this situation, parents are often stuck because they cannot envision an alternative perspective or path. They cannot imagine a way through the impasse between their faith and their child’s “choices.”

This can appear to simply be about rejection, but a closer examination may reveal that the underlying barrier is more about needing fresh ideas or information that might illuminate a possible path through this conflict between the parents’ faith beliefs and their love for their child. It is possible that the parents are not unwilling to be (more) accepting. Instead, with the knowledge they currently possess, the difficulty is their inability to envision a path through this impasse.

When this is the case, it is helpful to discuss whether the parents would be open to hearing how others have found a path through this dilemma. Would they be willing to explore other perspectives within their faith tradition? Would they be open to talking with other parents who have resolved similar concerns or conflicts? Would they be willing to talk with a pastoral leader/minister/rabbi/imam who might have fresh ideas on navigating this conflict between their faith/beliefs and their love for their child?

It can be useful to identify resources representing a range of faith communities that do accept and support transgender people. There are evangelical Christians who accept transgender people, such as Tony and Peggy Campolo and Matthew Vines. There are leaders within each branch of Judaism who are accepting. PFLAG can also be helpful in locating parents from different faith communities.

I am careful to stress that this is not about attempting to change parents’ beliefs. If my goal is to change their beliefs or I send a message to that effect, I am likely to lose them. I am simply asking if they would be willing to listen to others who have shared similar struggles with the hope that those experiences might help these parents envision their own path through this dilemma. In this scenario, the underlying obstacle is the lack of ideas and information and not the rejection in and of itself. In the long run, the exact beliefs they hold may be less important than the actions the parents take to communicate acceptance and support for their transgender child or adolescent.

After providing new information, therapists should check in with the parents or family about their understanding of what was shared. For example, you can say, “How does that sound to you? Does any of what I shared resonate for you? Does any of what I just discussed ring true in terms of your experience with your daughter? Does this sound like something you might be open to?”

Following up with these questions will clarify whether the family understood what you presented as well as elicit feedback about how they are processing this information. It may also bring to the surface additional questions they may have about the conversation. Parents, too, should always feel comfortable asking questions and sharing feelings.

Sometimes an emotional block precludes full acceptance from families. It is important for parents to identify the emotions underneath the outer layer of rejection and then create space for these feelings to be expressed. Yes, the father worries that John may not be able to know he’s transgender at 15 years old. Yes, the father worries that John will change his mind over time.

As a father shares these concerns, a therapist’s role is to reach for the feelings that shape the father’s worries. What emotions is this father experiencing underneath his concerns? Is it fear, anxiety, worry, anger, loss? As the father discloses his concern that John might change his mind, part of our work is to imagine, or be curious about, what feelings might drive that concern.

PARENTS, CAN YOU THINK OF SOME THINGS YOU HAVE SAID OR THOUGHT AND LINK THESE TO UNDERLYING EMOTIONS YOU HAVE?

Tentative language is helpful in reaching for underlying feelings. For example, as a therapist, you might say, “I wonder if underneath your worry that John may change his mind, you might also be afraid of losing him?” Or, “I could be way off base, but is there a chance that in addition to worrying about John, you also might worry about being an effective parent in this situation?” The tentative wording allows a parent to agree or disagree. If they agree, you can ask them to tell you more about this. If they disagree, they often go on to explain what they see as more accurate, or you can ask about this.

PARENTS, THE SAME IS TRUE FOR YOU. ALLOW YOURSELF TO EXPLORE WHAT YOU MIGHT BE FEELING IN A TENTATIVE WAY. THIS MAY GIVE YOU MORE SPACE TO ARRIVE AT A DEEPER UNDERSTANDING OF YOUR FEELINGS.

Anger is often a surface emotion when families are rejecting. Yet, anger is rarely the entire story for parents. When parents are angry about their child’s self-disclosure as transgender, appear rejecting of this identity, or oppose a social or medical transition step, the underlying emotions are often fear, hurt, or sadness. These are the feelings the clinician needs to bring to the surface and acknowledge in order to facilitate movement toward greater acceptance. It is these feelings that are the real barrier to acceptance, not the parents’ anger.

Therapy must provide a safe space for parents to explore and express these emotions. Bringing their grief, loss, fear, worry, anger, or disappointment out into the open where it can be acknowledged, expressed, and validated is essential for healing. As long as these feelings are hidden or unexpressed, the family will remain mired in conflict or rejection of their child’s trans identity.

The following vignette illustrates these strategies for facilitating greater acceptance—beginning where the family is, drawing out their concerns and validating them, reaching for underlying emotions, and creating a safe space to express these emotions.

As part of a project that offered family therapy to LGBTQ youth identified as at risk of becoming homeless due to parental rejection, I met with Juan, a 17-year-old young man who had run away several times. He was a sharp-dressing teen who paid great attention to his appearance. His gender presentation was highly feminine. He sometimes identified as gay, sometimes as trans, but more often as a gender-fluid femme man.

In our first appointment, Juan told me how much his mother hated him for being “femme.” They fought almost every time he left the apartment. He said he had run away before because of the mean things his mother would say to him when she was angry. He was clear that she rejected him because of his femme gender expression. Juan’s primary affect in our early sessions was anger toward his mother’s rejection of him, but there were moments when the hurt underneath his rage was apparent.

The first time I met Juan’s mother, I asked to meet with her alone. I did not think Juan was emotionally able to engage with her in a constructive way yet, and given his description of their interactions, I did not want to subject him to additional experiences of her anger and rejection.

The mother’s anger was apparent from the onset of our appointment. As I asked some initial questions about how she saw what was happening between her and her son, she launched into a tirade about his appearance. “It’s not right for a young man to dress like that. It’s just not right. All that makeup. Those girly clothes. It’s not right.”

She told me how much she disapproved of the friends he hung out with and the way they acted just like him. She hadn’t raised her son to be like this. Yes, she was a single mom, but she had taught him what a man should be like. No real man prances around like a girl. Maybe she should have his uncle beat some sense into him.

At about that point, I knew that some of my colleagues would be ready to write the mom off as hopeless. She seemed as rejecting of her son as Juan had told me, and there was very little room to get a word in edgewise. Each time I attempted to shift the conversation or offer an alternate perspective, her rage resurfaced and took over the discussion. She did not want to hear anything else—and perhaps (I suspected) especially not from a white middle-class professional man who was likely judging her as a working-class single Puerto Rican mom who clearly had not raised her son to be a real man.

In my experience, anger is rarely our first emotion. Anger is an emotion that almost always layers on top of either fear or pain. Anger can protect us from the profound discomfort of feeling afraid and powerless; it can create a cushion against the pain of being hurt by someone or something in our life. Juan’s anger toward his mother clearly functioned in part to protect him from the pain of her rejection of him. I wondered what might lie underneath his mother’s rage.

I also deeply believe what I wrote earlier about most parents loving their children and wanting the best for them. In part, this is rooted in knowing from experience that there is absolutely nothing my children could do that would ever erase my love for them. When I reach beneath the anger of most parents, this profound unconditional love is almost always there, even if deeply buried or scarred in the moment. The understanding that anger is rarely our first emotion and my belief that deep love is at the root of most parents’ psyche means I rarely accept what looks like parental rejection at face value. Instead, I maintain a passionate conviction that there is always more to the story.

As I met several more times with Juan’s mother, I was able to engage her in telling me what he had been like as a young child, what he liked and didn’t like, what made him laugh, what about him made her laugh, and what had made her proud of him. We explored her hopes and dreams for Juan. We talked about how she had tried to raise him and the kind of person she wanted him to be when he grew up. She told me that she and her sister had lived together for much of Juan’s childhood, that her sister loved Juan as if he were her own son, and how they had raised him together, sharing child care and doctor’s visits and parent–teacher conferences. She told me how much Juan loved his aunt. She was the one who had taught him to play baseball and bought him his first bike.

Her sister had been diagnosed with breast cancer two years before and was gone within the year. She and Juan were both devastated. As I brought us back around to what was happening between her and Juan now, I acknowledged that the depth of her love for her son was palpable. She nodded and began to tear up.

As we continued to talk, she began to tell me how afraid she was for her son. How terrified she was every time he left the apartment looking like “that”—“you know, like a girl.” She had heard boys like Juan being called “faggots” or “maricón,” getting beaten up, sometimes left for dead. When Juan’s boyfriend picked him up, she worried they wouldn’t make it to the nearest subway station 10 blocks away without someone harassing them. It was this fear that fueled her anger. Underneath all the anger, Juan’s mother wasn’t rejecting; she was terrified of losing him. This would have been difficult enough to navigate on its own, but so close on the heels of losing her sister, the fear was unbearable for her.

Within the next few weeks, I was able to bring Juan and his mother in together. With coaching, Juan was able to tell his mother how much her anger hurt him, how it made him feel as if she didn’t love him anymore, and how this was even more painful alongside his grief about losing his aunt the year before. His mother was able to share her fears, how much she worried for his safety, how alone she had felt since her sister died. She told Juan she couldn’t bear to think of losing him as well, and so she yelled at him for going out “like that.” Together we were able to reframe the mom’s rage. It didn’t mean she rejected who he was. In fact, it meant the opposite. The intensity of her anger reflected the depth of her love for him, how important he was to her, and how much she wanted him to remain in her life.

Working with Juan and his mom confirmed my belief that as clinicians, we can never write a parent off. We can never blithely accept what may look and sound very much like rejection on the surface. There is almost always more to this story. It’s our profound responsibility to reach for what may lie underneath the rage and disapproval. Our understanding now about the critical role family acceptance plays in the health and well-being of these young people demands that we reach for what might yet be love, buried deep beneath the parent’s seeming rejection.

As illustrated above, when parents or other family members are deeply embedded in anger or rejection, one strategy is to try to step back from their anger for a moment and then invite memories of when the child was younger.

A therapist might say, “I wonder if you would be willing to step back from what you are feeling [or from what we have been discussing] for a moment? If you would be willing to shift gears and share some of how you felt when he/she was young. What were your feelings when he/she came into your life? What hopes or dreams did you have for them?”

These kinds of conversations often make it possible to link hopes and dreams to the importance of acceptance and support. These hopes and dreams can be realized, but only with love, acceptance, and support.

FOR PARENTS, WHEN YOU THINK BACK TO YOUR FEELINGS OR HOPES AND DREAMS FOR YOUR CHILD FROM EARLY ON ALONGSIDE WHERE YOU ARE TODAY, WHAT FEELINGS COME UP?

Even a small movement away from rejection and toward acceptance can decrease the young adult’s risk factors (Ryan, et al., 2010). Given this, when family members have shared some of the positive dreams they held for their child, I may ask if there are one or two rejecting behaviors they might be willing to stop doing and one or two accepting behaviors they would be willing to begin doing. Many times the agreement I strive for is to have them try out these shifts for one to two weeks until we meet again. I frame the agreement in this short-term context. This is not about changing how they interact with the child permanently. It is about not doing or saying one or two things that convey rejection and trying out one or two accepting behaviors or messages for this brief time period so that we can come back and discuss it further.

It can be helpful to draw on a harm reduction framework. I ask the parents if they are willing to refrain from one rejecting behavior and begin practicing one accepting behavior, not because they have changed their minds and now believe being transgender is OK, but simply because of what we know now about the long-term impact of parental actions on children. I stress that my goal is not to change their beliefs but to increase the chances that their child will grow up to be healthy and alive.

Getting parents to stop even one rejecting message or action and begin even one new accepting practice can facilitate a greater sense of acceptance for the trans young person. It communicates that their parent is willing to try—that their parent loves them enough to try something different simply because it may make a difference for the young person. It demonstrates commitment to the youth on the parent’s part.

Another intervention strategy involves exploring the value of love within families and what it looks like to live out this value within their family. I explore whether families can love each other without necessarily agreeing about everything with each other. I explore whether it is possible for families to express unconditional love and acceptance, without that necessarily meaning condoning every individual choice or behavior. I believe the answer to both questions is yes, though living this out within families can certainly be challenging. If love is a primary value for a particular family, this exploration can be worthwhile. Knowing what the research says about the pivotal importance of unconditional love for transgender adolescents supporting a family as they grapple with how to live out their love for each other, despite possible differences, can be invaluable.

Potential Pitfalls or Biases With Families From Conservative Faith Traditions

•Progressive or nonreligious therapists not understanding conservative religious beliefs

•Belittling conservative religious beliefs or minimizing their significance to families

•Prejudgment of these families

•Perceiving parents as not loving their child enough; viewing parents as placing a higher premium on their beliefs than on their child’s well-being

•Pushing families to choose between their religious beliefs and their child rather than looking for ways to expand options/paths

Question: Can families from conservative faith traditions believe that being transgender is wrong or sinful and still accept their transgender child?

Reflection: This is a challenging question for many mental health providers as well as transgender individuals. There are some who would say this is not possible—that when parents believe it is wrong or sinful for their child to identify as transgender, this inherently equals parental rejection. In my experience in working with families, I am no longer sure this is always the case.

There is no question that there are many transgender youth growing up in families who understand trans identity to be “against God’s will,” and some of these parents do reject their children as a result of this belief. In some situations, this rejection is complete enough to result in the trans youth being kicked out of their family’s home. However, I also believe that we, as mental health professionals, need to resist viewing acceptance and rejection as an either/or proposition. This is the same kind of polarized thinking that families from conservative faith traditions are often accused of.

Instead, as we can see from the Family Acceptance Project research, family acceptance and rejection can be viewed on a continuum, not just as polar opposites (Ryan, et al., 2009; Ryan, et al., 2010). This means that there can be degrees of acceptance and rejection within individual families. It means that acceptance and rejection are not necessarily mutually exclusive.

On a purely pragmatic level, if we operate with the assumption that acceptance and rejection are mutually exclusive and conclude that parents cannot view being transgender as sinful and accept their child, we preclude any possibility of engaging these parents and facilitating change or increased acceptance. And this is true whether or not we verbally express this opinion. Even if we are silent about our assumption, it is likely that our nonverbal communication will inevitably convey this judgment to the parents.

As fine as this line might be, I have worked with some parents from conservative religious communities who did find a way to hold their beliefs in one hand and yet also be clear about their unconditional love for their child. The mother of a 17-year-old nonbinary youth with whom I worked often read fundamentalist Christian literature while in my reception area. Yet, as I talked with this mother, it was evident that she had found a way to navigate her church’s beliefs alongside her love for her child.

The mother remained unsure that it was OK to be transgender; the mother still believed that sex and gender identity were the same in “God’s eyes.” At the same time, she stated she loved her child unconditionally. When we met, the mother was able to acknowledge her own religious beliefs and her struggle with how all this fit together, yet simultaneously tell her child that she loved them unconditionally.

I did some coaching with the young person about being able to see that acceptance did not always have to equal agreement—that their mother could love them unconditionally, yet not always agree with them—in the same way that they might love a partner sometime down the road and not necessarily agree with that person about everything.

Some of you might be thinking you are not so sure this is possible. That you’re not convinced the mother really unconditionally accepted her child if she still thought being transgender was a sin. You might think the young person would not feel loved if the mother still held those religious beliefs. I concede that this is a fine line. Nonetheless, I believe it is sometimes possible to help families walk this line and hold these two seemingly opposed positions in tandem without either canceling the other out. And if this is the closest I can get to acceptance in the moment and it means that there’s a better chance that another transgender young person stays alive, I’ll take it.

We need more research about families within conservative faith traditions who are accepting of their LGBT youth. We need to better understand how these families reach a place of acceptance even if their beliefs do not change. We need to understand what enables them to make this leap. Knowing how some families successfully navigate this dilemma might enable us to better understand how we can facilitate this movement into unconditional love and acceptance for other families—even when their religious beliefs may not change.

A young person’s gender identity is not always the whole story in working with their families. Many times the work may move well beyond the child’s gender identity to engage other family dynamics that are less than optimal or unresolved.

In the course of working with one transgender adolescent, the nature of his struggles led to extensive family work around unresolved aspects of the parents’ divorce, the father’s largely unacknowledged addiction, and the impact of a grandmother’s alcoholism.

In work with another family a generational pattern emerged of not discussing major events in the life of the family. It was sparked by my discovery several months into our work (ostensibly focused on a 13-year-old trans girl) that the mother had recently been diagnosed with her third round of breast cancer. Not only had no one told me about the mother’s reoccurrence, neither parent had talked to their children about this – as in never mentioned it to the two young people.

As we processed this issue the father shared that his father had been tragically killed in an accident when he was only five years old. His mother never told him anything about the accident, and in fact never mentioned his father again. She just moved on as if there had never been a father in his life.

Both of these scenarios reflect the fact that while work with families of trans youth may begin with a young person’s coming out as trans, it may go anywhere from that disclosure. It is important to be prepared for this likelihood and have an awareness of the level of your clinical skills in work with families. It may be that some families need to be referred to a more senior family therapist if more complex family challenges and patterns emerge as they did in these two families.

COUNSELOR:	Tell me what worries you about John’s understanding of his gender identity. [I use “John” here because we are still in the initial sessions and the father is using “John”].
FATHER:	I just don’t think he can know at 15 whether he’s transgender or not. He’s too young. Teenagers are always exploring their identity. Today he thinks he’s a girl. Tomorrow it will be something else.
COUNSELOR:	It’s true that exploring identity is often part of adolescence. Tell me more about how that connects to your reluctance to believe John’s understanding of himself as a trans girl.
FATHER:	I just don’t think he should make a decision like this at his age. How does he know he’ll still feel the same way in 10 years?
COUNSELOR:	It worries you that he might change his mind later on?