Recently, I had the pleasure and privilege of a teenager coming out to me as gay. The process of this discovery was a long one. He disclosed to me that he had seen a movie, Call Me By Your Name, that he found arousing. We had a long conversation about sexuality and how it falls on a spectrum. I explained that most people’s sexualities are not “either, or” and that they fall on a line of multiplicity. I normalized questioning his sexual identity and affirmed his experience. I also discussed the impact of his growing up in a conservative Christian household and the resulting fear of disclosing his identity.
Over the years, I have had the honor and privilege of multiple adolescents “coming out” to me. In the intake session, I ask the youth their pronouns and sexual orientation. The majority say that they are “straight.” Sometimes, almost instinctively, I can tell they are not being authentic. I do not press for more information; I simply smile and process the intake. Sometimes, the child comes out to me later that session. When they do, I praise them and tell them what an honor it is to be the first person to hear that. We discuss all their questions and I normalize their experiences. This, I found to be one of my greatest rewards as a clinician—holding space for a marginalized person and accepting them for who they are.
Such clients can benefit from the systemic framework of marriage and family therapists (MFTs). One specific area is our acknowledgment of internalized homophobia/transphobia that they have acquired from within their family system. Many times, families do not discuss sexual orientation or gender identity. It is often an unspoken rule within the family unit. As a result, many of our clients grow up learning that these topics are shameful and unworthy of conversation. It may not be that the caregivers are not accepting. Oftentimes, these behaviors are acquired within their own family of origin. As MFTs, we can discuss the family’s unspoken and spoken rules regarding LGBTQIA+ conversations. By exploring the underlying assumptions we make in our own families, we are better able to understand how these presuppositions impact us.
I recently received a referral for a client who was having “identity issues.” In the first session, I asked their pronouns and they said, “He, Him.” Their parents did not know that they identified as a trans male and that he had been living as a man at school for two years. He had been in therapy for two years before me and disclosed that he did not feel comfortable sharing his pronouns with his therapist. He explained, “She never asked me how I identified in the assessment part, so I never felt comfortable telling her.” After one session of me affirming his gender, he expressed that no one had ever spoken to him in this way before. He disclosed his gender identity to his parents after our session. When I talked to him the next week, he told me that I was the first adult who had believed in him; “I just felt like if I had someone like you on my side, I could do anything. I never had an adult treat me the way you have.” I held the following session with the entire family and discussed the parents’ underlying assumptions about gender, identity, and sexuality that they learned in their own family units. As a result, the client was able to feel affirmed and accepted. He was also surprised by his own family’s acceptance as his sexuality and gender were a topic that were never discussed.
As a practitioner of gender-affirming care (GAC) and family systems, I believe supporting our clients’ identities literally saves lives. GAC is a supportive form of healthcare. It consists of an array of services that may include medical, surgical, mental health, and non-medical services for transgender and nonbinary people. It is a model that believes each client’s transition journey is individualized. GAC accepts the person’s identity and assists them in obtaining assistance that supports their transition (Osserman & Wallerstein, 2022).
Giving clients space to explore their gender and sexual identities: Why is this important?
According to the Trevor Project (2021), lesbian, gay, bisexual, transgender, queer/questioning, intersex, and asexual (LGBTQIA+) students are four times more likely to attempt suicide. They report that at least one LGBTQIA+ youth attempts suicide every 45 seconds. The survey captured nearly 34,000 LGBTQ youth between the ages of 13-24 in the United States. The Trevor Project’s National Survey on LGBTQ Youth Mental Health reported disclosing their sexual orientation to at least one adult. Among those who disclosed to at least one adult, 79% had at least one adult who was accepting of them. Over one-quarter of LGBTQ youth who did not have at least one accepting adult in their life reported attempting suicide in the past year compared to 17% of those with at least one accepting adult. The positive impact of acceptance from at least one adult on past year suicide attempt was statistically significant.
A recent study by the Journal of Adolescent Health found that transgender and nonbinary youth were 2 to 21/2 times more likely to experience depression and attempt suicide (Green & Dorison 2020).
American attitudes towards LGBTQIA+ people are slowly shifting; however, there are still currently many laws in place across this nation that directly discriminate and remove their civil rights.
The most banned book in the United States, All Boys Aren’t Blue, is a story of a young Black queer adolescent navigating the challenges of being an LGBTQIA+ person in the U.S. It is currently banned in 130 districts in America. Children and teens in these districts are kept from learning about others’ lived experiences. This delays their journey to themselves and further stigmatizes LGBTQIA+ stories as wrong, dirty, and secretive. I have read this book and found it resonated with me on so many levels. I could only imagine what it could do for LGBTQIA+ children in areas where they cannot access this material. American attitudes towards LGBTQIA+ people are slowly shifting; however, there are still currently many laws in place across this nation that directly discriminate and remove their civil rights. That is why educating ourselves as clinicians is important.
Labels, labels, labels
Now, let’s discuss the power of pronouns and identities. There are a plethora of pronouns that have developed in the past few years. Many people find them overwhelming, yet, with practice, I believe we can all adapt to this form of inclusive language. Let’s go over a few: I will start with some gender identity labels and then transition to some on the sexual identity spectrum.
What is the gender binary?
“The gender binary is a cisgender-normative categorical system in which there exist two mutually exclusive genders (male/man and female/woman) and immutable ways of expressing those genders” (Chang et al., 2018, p. 57). Many people are confused about what constitutes a non-binary person. There are many terms with which nonbinary people identify, so it is best to think of the term as an umbrella rather than a fixed point. As clinicians, we must listen to our clients’ lived experiences without pushing them under one label.
>>AAMFT Webinar: Providing Quality Care to LGBT Patients
It is important as clinicians not to make any gender binary assumptions. If we are culturally competent and self-aware of the influence of our own backgrounds, we can better view our clients through an unobstructed lens. We should all adopt a curious stance and empathic understanding.
Some nonbinary identities
Demigirl, gender diverse, gender nonconforming, gender variant, genderqueer, neutrois, multigender, pangender, stud, demiboy, bigender androgyne, mixed-gender.
Gender vocabulary
Binary: The assumption that gender is binary (male or female)
Cisgender: A person who identifies with the gender identity assigned at birth
Gender expression: How one presents their gender to others externally
Gender identity: One’s internally known gender
Non-binary: Any gender that is not solely male or female
Transgender: A term that encompasses an array of identities that oppose traditionally defined gender norms
Sex: Refers to body characteristics such as one’s genitals, endocrine system, gender identity, and has a traditional focus on being “male or female”
Genderqueer: Someone who does not identify with the binary
Gender variant: A person who does not conform to gender expectations
Intersex: A person who has hormones, internal sex organs, and genitals that do not meet the expected characteristics of male or female
Passing: A term often used by transgender people when referring to being accepted or able to “pass” as a cisgender person
Terms to avoid: “Born a girl or boy, biologically male or female, biological sex”
(Safezone Project, 2015).
Sexual identity
Aromantic, Asexual, bicurious, demiromantic, demisexual, dyke, gay, gray, heterosexual, questioning, queer, straight, pansexual, lesbian, bicurious.
Many transgender people feel that the common terms of bi-sexuality, heterosexuality, and homosexuality fall within the binary. In summary, the terms are closely associated with one’s gender. For example, a cisgender man attracted to men is “gay” and a cisgender woman attracted to women is a “lesbian.” As a result, many transgender people identify as “queer” “as it is a useful umbrella term that does not require one’s sexual orientation to be relative to their assigned sex or gender identity (Sand, 2018).
>>AAMFT Webinar: Addressing Suicide Among LGBTQ+ Youth
When working with people who are exploring their own sexual identities and genders, if we approach them with a non-binary stance, they feel a congruence in the therapeutic relationship. This congruence creates a safe place for them to explore.
With any client, never assume their pronouns based on their gender presentation. Always ask. This asking creates the beginnings of a safe space to explore. Here are some pronouns you might encounter: Ze/zir, ze/hir, ey/em, ve/ver, ne/nem, fae/faer, they/them, he/him, she/her, xe/xem. I find the website practicewithpronouns.com to be particularly helpful in learning their usage.
We are often the first models of what support and acceptance can look like.
Caregivers
In my practice, oftentimes the young person’s family is unaware of their sexual orientation or gender identity. Other times, I have come across caregivers who are aware and unsupportive of the client. That is why our job of affirming them is so important. We often provide a corrective emotional experience. According to the American Psychological Association parent’s rejection of their child’s sexual orientation causes mental health issues (2009). Research concluded that these teenagers were over eight times more likely to have attempted suicide and five times more likely to experience depression. That is why I believe the gender affirming model can save lives. We are often the first models of what support and acceptance can look like.
What can we do to support them?
Help them acquire skills for resiliency that teach them to stand up for themselves (boundary setting), build self-esteem, affirm and enjoy their bodies, and examine internalized homophobia/transphobia (Singh, 2018). As MFTs, we can explore the boundaries within their family system. Oftentimes, if they are of a high context culture (more enmeshment), this can be particularly challenging without coming off as disrespectful. However, if the youth does not eventually learn to set clear boundaries with their family in terms of their identities, they will suffer later in life. That being said, many youth will be unable to “come out” to their families due to fear that they will not be allowed to remain in their households. As a result, you may be the only “safe” person in their lives where they can be their authentic selves.
I would encourage clinicians to discuss your clients’ learned stereotypes about being an LGBTQIA+ person that were learned in their family. Ask them what they have heard about this population from their parents or peers. The teachings they have acquired will often be geographical and have been influenced by your client’s race, ethnicity, and socioeconomic status. By naming these experiences, your client can learn to challenge and overcome them in order to build self-esteem and confidence in their identities.
Another important message for teens and kids to learn is that they are more than the label with which they identify. As clinicians, we should assist them in listing positive traits/attributes that they see in themselves. If this is difficult, ask them what their best friend or loved one would say about them. If your client is to navigate a bigoted and transphobic society, it is critical to help them in building this confidence and resiliency to fight the statistics going against their mental health.
How to have conversations about sexual identity when they are ready
One resource I use is www.Advocatesforyouth.org. They have several pamphlets that provide information and ask valuable questions to navigate your client’s process. Some questions to ask:
“When I dream or fantasize sexually, who do I think about?”
“Can I imagine myself dating, having sex with, being in love with or marrying…”
“How are my feelings towards men, women, and non-binary people different?”
“Do I feel ‘different’ from my ‘straight’ friends when they talk about people they like?”
It is equally important to remind clients that labels are not necessary. Emphasizing that their sexual orientation falls on a spectrum means exactly that. Sometimes labels can be frightening for people. Encourage them to keep an open mind when asking these questions to themselves and trust what feels comfortable and true.
>>Clinical Guidelines for LGBTQIA-Affirming Marriage and Family Therapy
Lastly, you want to help your client build a community of support around them. Many schools have an LGBTQIA+ group on campus. There is also a multitude of support resources online. Hearing stories of other LGBTQIA+ people empowers children to feel comfortable in their skin.
I encourage MFTs to remember our focus is the client and family system. We should not question our clients’ gender or sexual orientation. We must accept their realizations. Our job is to support our clients. We should not deny their lived experience. I believe that, as clinicians, we have a unique opportunity presented to us in a nation that is continually evolving. We can support our clients by providing them with safe and accepting spaces to share their deepest realizations. As a matter of safety, we cannot reject them and express the belief that we know more about them than they do. I humbly ask my fellow clinicians: on which side of history do we want to be?
Gretchen Anne Cooper, MA, LMFT, (she/her), graduated with her BA in Philosophy from the University of La Verne and received her MA in Psychology from Phillips Graduate Institute (PGI) in Los Angeles. She is currently in private practice in California and adjunct faculty at Philips Graduate Institute’s Master of Marriage and Family Therapy Program, Los Angeles Education Center of Campbellsville University. She worked in community mental health for several years before transitioning to her private practice in 2021, full time. During her time in the county, Cooper acquired a passion for serving individuals from a multitude of backgrounds. It was there that she developed a passion for working with LGBTQIA+ youth. She specializes in working with adults, LGBTQ+, adolescents, the unhoused, and children. She published her thesis on Animal Assisted therapy with Children on the Autism Spectrum. Her family member is transgender and Cooper, herself, is also a member of the LGBTQIA+ community.
www.gretchencooper.com; Instagram @gretchencooperlmft
American Psychological Association. (2009). Parents’ rejection of a child’s sexual orientation fuels mental health problems. Retrieved from https://www.apa.org/monitor/2009/03/orientation
Chang, S., Singh, A., & Dickey, L. (2018) A clinician’s guide to gender-affirming care Context Press.
Green, A., & Dorison, S. (2020). Understanding the mental health of transgender and nonbinary youth. Retrieved from https://doi.org/10.1016/j.jadohealth.2019.11.314
Osserman, J., and Wallerstein, H. (2022). Transgender children: From controversy to dialogue. The Psychoanalytic Study of the Child, 75(1), 159-172.
Safezone Project. (2015). Transgender vocabulary. The Guardian, Gender Dictionary.
Singh, A. (2018) The queer and transgender resilience workbook: Skills for navigating sexual orientation and gender expression. New Harbinger Publications.
The Trevor Project. (2021). Facts about LGBTQ youth suicide. Retrieved from https://www.thetrevorproject.org/resources/article/facts-about-lgbtq-youth-suicide/
Forsythe, A., Pick, C., Tremblay, G., Malaviya, S., Green, A., & Sandman, K. (2022). Humanistic and economic burden of conversion therapy among LGBTQ youths in the United States. JAMA Pediatrics, 176(5), 493-501. doi:10.1001/jamapediatrics.2022.0042
Stryker, S. (2017) Transgender history the roots of today’s revolution. Revised Edition. Seal Press.
Yogman, M., Baum, R., Gambon, T., & Lavin, A. (2018). Ensuring comprehensive care and support for transgender and gender-diverse children and adolescents. American Academy of Pediatrics, 142(4).
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