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Affirmative Therapy with Trans and Gender Expansive (TGE) Youth and Their Parents

Deb Coolhart, PhD

When youth are expressing gender expansiveness or claiming a trans identity, it is common for parents to seek therapy for help navigating their child’s process. Parental attitudes vary widely and may include full support, relief, confusion, disbelief, fear, loss, anger, or outright rejection. Regardless of a family’s level of attunement with the youth’s expression/identity, it is vital for therapists to use a gender affirmative approach. TGE youth face minority stress and are often experiencing dysphoria, stressors that can lead to increased mental health problems, including depression, anxiety, and suicidality. A gender affirmative approach is the first step to counterbalancing the negativity youth face both in their external environments and within self (i.e., internalized transphobia, dysphoria). This approach assumes that no gender identity or expression is pathological (Keo-Meier & Ehrensaft, 2018), that they are all natural variations of humanity (Coolhart & Shipman, 2017), and that any pathology that is present is a result of transphobia, homophobia, and sexism, rather than a disturbance in the child (Coolhart, 2012; Hidalgo et al., 2013).

Following are some strategies for working with TGE youth and their parents. For a deeper discussion of interventions, please see other published works on this model (Coolhart, 2012; Coolhart, 2018; Coolhart, 2019; Coolhart, Baker, Farmer, Malaney, & Shipman, 2013; Coolhart, Ritenour, & Grodzinski, 2018; Coolhart & Martin, in press; Coolhart & Shipman, 2017).

Assessing parental attunement and deciding on the structure of sessions

Starting with the first phone call, therapists can begin to assess how much harmony, understanding, and peace parents are experiencing around their child’s gender expression/identity. When parental attunement is low, therapists should work with parents separately from the child in order to provide space for the parents’ concerns without sending harmful messages to the child. Family sessions can begin when therapy can be an emotionally safe place for all members, where youth and parents can have healthy and productive discussions about gender expression/identity.

Supporting gender expansiveness

TGE youth have often experienced a broad range of disapproval of and opposition to how they experience and express gender, coming from multiple sources such as parents, siblings, peers, neighbors, teachers, religion, and media. Therapists aim to balance these negative messages by 1) delivering positive messages about TGE expressions/identities, 2) normalizing and validating TGE experiences, and 3) recognizing the strengths and resiliencies TGE youth have as a result of their journey with gender. Therapists should ask about chosen name and pronouns and use them with the youth, creating a “gender expansive safe zone,” where youth are free to dress and express themselves in congruent ways.

When TGE youth are requesting the use of pronouns that differ from those assigned at birth, parents sometimes struggle to make the transition. Therapists can help parents understand why pronouns are so important and the pain it causes when one is misgendered. If it feels emotionally safe for the youth, therapists can coach youth in talking to their parents about the impact on them when incorrect pronouns are used. A strong therapeutic relationship with parents is important so therapists can begin to challenge parents’ behavior that is not supportive of their child’s expression/identity, including using incorrect pronouns. When parents have particularly low attunement, therapists can use they/them pronouns and gender neutral language (i.e., “your child”) in order to respect both the parents and the youth in their processes.

It is vital to follow the lead of youth and listen to what they need to feel congruent.

Providing psychoeducation

Parents of TGE youth often need accurate information about gender-related concepts (i.e., the differences between sex, gender identity, gender expression, and orientation) as well as TGE experiences (i.e., TGE kids can grow up to be healthy adults). Therapists can also educate parents about the importance of parental support, which can buffer youth from negative mental and physical health outcomes. Youth with rejecting parents are at increased risk for suicide ideation and attempts, depression, illegal drug use, alcohol abuse, smoking, homelessness, engaging in unprotected sex, and sex work; those with supportive parents may experience higher self-esteem, social support, general health status, school belonging, academic achievement, life satisfaction, and overall mental health. Thus, even when parents are struggling to accept their child’s TGE expression/identity, therapists can gently coach parents to decrease their rejecting messages. Finally, parents sometimes worry about what caused their child to be TGE. Therapists can reassure parents that being TGE is a natural variation of humanity, that TGE people have existed over time and across cultures, and that there is nothing they did or didn’t do that caused their child to be TGE.

Supporting parents’ emotional process

Parental reactions to having a TGE child vary and can include many different emotions, such as joy, relief, anxiety, embarrassment, worry, anger, denial, shame, self-blame, disappointment, loss, confusion, or fear for their child’s safety. Therapy can be a space for parents to express and process all of these feelings so that parents can be freed up to be more attuned to their child. When parents are expressing particularly negative views about their child’s TGE expression/identity, it can be difficult as an affirmative therapist to listen to these anti-affirmative views. However, it is important that therapists manage their reactivity and find a way to feel compassion for these parents. It is the children of these more rejecting parents who need us the most and if a therapist loses the parent, they likely lose the ability to help the child.

While supporting parents in their process, therapists can explore the context in which parents developed their views about gender. After exploring gendered messages received by parents’ families of origin, religion, racial/ethnic community, or media, therapists can begin to challenge parents to stretch and expand. Therapists may discover that parents also had experiences in which gender expectations didn’t fit; the feelings around these experiences may be explored in order to find connections between parents’ and their child’s experiences.

Finally, parents sometimes have a sense of urgency, wanting to know whether or not their child is “actually” transgender and if their child will need to socially and/or medically transition. Parents can be encouraged to focus on the child’s journey rather the outcome. Therapists can emphasize that what their child is experiencing right now is important and real for them, and parents can be encouraged to respond to their child in the moment by listening with compassion, patience, and support.

Listening to youth about what they need to feel congruent

This final technique is really the central goal in therapy. Once the parent-child dynamics are stabilized, it is vital to follow the lead of youth and listen to what they need to feel congruent. Some TGE youth very clearly and persistently assert a gender identity that is different from their assigned sex, while other youth simply need space for a gender expression that differs from the expectations of their assigned sex. The latter youth are gender expansive and may not ever need to transition to another gender identity. They may just need to feel free to express gender in a way that feels congruent. Parents can be encouraged to support their child’s creativity and talk with their child about how to handle opposition to their expression when it arises in contexts such as school or with extended family.

Father and Son

Other youth assert a non-binary identity, and identify as both female and male, neither female nor male, or more female at times and more male at other times. Again, therapists can encourage parents to support whatever gender expressions feel congruent for the youth. Non-binary youth often request the use of genderless pronouns, such as they and them, and sometimes the use of a chosen name. Non-binary youth may or may not experience body dysphoria, therefore the path to congruence may or may not include social and/or medical transition.

Finally, many youth assert a binary gender identity (female or male) that is different from their assigned sex. Some youth are very clear about their identity as early as they can remember, while other youth may not understand their gender identity until adolescence. When youth become clear about their binary identity, most wish to take steps towards gender transition in order to experience congruence. Based on a growing body of research that suggests positive outcomes for youth who are able to transition early, the gender affirmative approach supports exploring youth and parental readiness for gender transition options.

When this balance is achieved, it can sometimes provide the loving space needed for parents to grow in their attunement with their child, learning to really listen to what their child needs to feel congruent.

While there may be reasons to delay transition for some youth (i.e., uncertainty with identity, lack of support), transition can be urgent for other youth. When youth are experiencing high levels of distress (i.e., dysphoria, depression, anxiety) and demonstrating persistence with their gender identity, transition may be vital for the youth’s mental health. Transition is a process that is unique to each person and can involve many steps. As youth take small steps in the process, therapists can then check in to make sure the steps taken are resulting in increased feelings of congruence. For example, when a youth starts using their chosen name, how does it feel? Better?

Transition can also be thought of as having both social and medical steps. Social transition typically includes coming out to others and choosing clothing, hairstyle, name, and pronouns that feel congruent with the youth’s gender identity. Medical transition may be considered as puberty draws near or if youth is already in puberty. Prepubescent youth may desire the use of hormone blockers to delay puberty. Hormone blockers give youth more time before initiating less reversible treatments, prevent the body from going into the “wrong” puberty, and can reduce distress for youth who are concerned about their body changing. Because pubertal delay prevents the development of secondary sex characteristics, it may lead to more body satisfaction and a desire for fewer medical/surgical treatments later in the transition process. Additionally, hormone blockers, which are fully reversible, allow parents more time to process their child’s gender transition before taking less reversible steps.

As youth get further into puberty, many wish to begin feminizing or masculinizing hormonal treatment in order to experience pubertal changes that are typical of their gender identity. Many youth beginning hormone therapy experience excitement and relief because their bodies are beginning to match their minds, thus decreasing dysphoria and often decreasing mental health symptoms. While many of the physical changes caused by hormone therapy will reverse if discontinued, some effects of hormones are not fully reversible, such as breast growth, voice pitch drop, and facial/chest hair. Long-term data on the health risks of hormonal intervention in youth are not available due to the relative newness of the gender affirmative approach. While there are some potential risks involved in these treatments, such as the loss of reproductive ability, the benefits to the child’s mental health and future adult functioning often heavily outweigh the risks (i.e., suicidality).

While genital surgery is not available for youth under the age of 18 at the time of this writing, some transmasculine youth undergo chest reconstruction surgery. This eliminates the need for youth to bind (compress) their chest, which can be painful, hot, uncomfortable, and can restrict breathing. Chest dysphoria is often very intense for transmasculine youth and chest reconstruction can often eliminate this distress.

Systemic therapists, with their openness to understanding multiple perspectives, are in a unique position to support not only TGE youth, but also their parents. While some parents are able respond to their TGE youth with full acknowledgement and support, other parents struggle to understand, accept, and affirm their children’s TGE expressions/identities. Family therapists can meet parents where they are and allow space for their emotional process, while at the same time support TGE youths’ expressions and identities. When this balance is achieved, it can sometimes provide the loving space needed for parents to grow in their attunement with their child, learning to really listen to what their child needs to feel congruent.

Deb A. Coolhart, PhD, LMFT, is an AAMFT Clinical Fellow and Approved Supervisor. Coolhart’s scholarly interests include clinical issues related to marginalized and queer experiences/relationships and intersectionality, with a particular focus on clinical issues of trans people and their families. Her research and publications have focused on trans youth and their families, trans family support, nonbinary experiences, and trans sexuality. Clinically, Coolhart has been working with trans people for over 20 years and has become a nationally recognized expert in the area, providing regular consultation for professionals working with the trans population. She is a national speaker, regularly presenting on working with LGBTQ youth, their families, and school systems. In 2004, Coolhart created the Gender Expansive Support Team, housed in Syracuse University’s Couple and Family Therapy Center, where students gain specialized training working with trans people and their families, including working with clients regarding their readiness for medical gender transition. Additionally, Coolhart is coauthor of The Gender Quest Workbook, which has sold over 20,000 copies.

REFERENCES

Coolhart, D. (2012). Supporting transgender youth and their families in therapy: Facing challenges and harnessing strengths. In J. Bigner & J. Wetchler’s (Eds.), Handbook of LGBT-affirmative couple and family therapy. New York: Routledge Press.

Coolhart, D. (2018). Helping families move from distress to attunement. In C. Meier & D. Ehrendaft’s (Eds.), The gender affirmative model: An interdisciplinary approach to supporting transgender and gender expansive children (pp. 125-140). Washington, DC: American Psychological Association.

Coolhart, D. (2019). Please stop calling my daughter ‘he’: Advocating for teens and pre-teens in the school setting. In A. I. Lev & A. Gottlieb’s (Eds.), Families in transition: Parent perspectives on raising the gender nonconforming or trans child. New York: Harrington Park Press.

Coolhart, D., Baker, A., Farmer, S., Malaney, M., & Shipman, D. (2013). Therapy with transsexual youth and their families: A clinical tool for assessing youth’s readiness for gender transition. Journal of Marital and Family Therapy, 39(2), 223-243.

Coolhart, D., & Martin, T. K. (in press). Gender affirmative therapy with trans and gender expansive youth: Listening to youth and thoughtfully following their lead. In R. Harvey & M. Murphy’s (Eds.) Handbook of LGBT-affirmative couple and family therapy (Second Edition). New York: Routledge Press.

Coolhart, D., Ritenour, K., & Grodzinski, A. (2018). Experiences of ambiguous loss for parents of transgender male youth: A phenomenological exploration. Contemporary Family Therapy, 40(1), 28-41.

Coolhart, D., & Shipman, D. L. (2017). Working towards family attunement: Family therapy with transgender and gender nonconforming children and adolescents. Psychiatric Clinics of North America, 40, 113-125.

Hidalgo, M. A., Ehrensaft, D., Tishelman, A. C., Clark, L. F., Garofalo, R., Rosenthal, S. M., Spack, N. P., & Olsen, J. (2013). The gender affirmative model: What we know and what we aim to learn. Human Development, 56, 285-290.

Keo-Meier, C., Ehrensaft, D. (2018). The gender affirmative model: An interdisciplinary approach to supporting transgender and gender expansive children. Washington, D.C.: American Psychological Association.