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Authenticity and Safety — Family Therapy With Transgender Teens
By Irwin Krieger, LCSW

Social workers in a wide range of settings are encountering more teenagers who identify themselves as transgender. My clinical practice over the last eight years has been increasingly focused on these teens and their bewildered parents.

When such a family arrives at my office, the parents are usually confused, fearful, disbelieving, and angry.  They know little or nothing about transgenderism. The teen, on the other hand, has done extensive research online and has seen numerous video blogs of others transitioning. Teens usually tell their friends before they tell their parents, often with a good response. They may also be communicating online with other transgender teens and adults. They are informed, usually impatient to transition, insistent, and angry. They feel misunderstood by their parents, who seem to be throwing up unnecessary obstacles to their progress. 

Parents, meanwhile, are focused on keeping their child safe from harm, including the harm of taking steps to what seems to them to be a crazy endeavor. Teens are focused on authenticity, on actualizing their true selves, regardless of any uncertainties or potential difficulties. As the therapist working with these families, I see myself as a bridge between these two values of authenticity and safety—which initially seem to be at odds. Over time, most families can work together, honoring both of these values and arriving at a good outcome. In the process, parents must find ways to understand how their teen feels inside, and teens must collaborate with their parents to figure out a reasonable path forward.

Information Gathering
The first thing parents in this situation need is a lot of information. This includes the concepts of sex, gender identity, gender expression, and what is meant by transgender and transsexual.They need to know that sexuality is separate but interacts with gender identity and that sexual orientation occurs along a spectrum. Parents also need a thorough understanding of their teen’s specific thoughts, feelings, and desires.

Too often a teen will drop the bombshell of coming out transgender and then say nothing more about it to his or her parents. The parents’ first responses are generally to challenge the veracity of what their teen is saying, and then communication breaks down completely.

It is essential to explain to these teens that even though it is normal for them to be moving away from parents and toward their peers, in this case, it is important to keep open the line of communication with their parents. I often find it helpful to have a session in which I interview the child in front of the parents to elicit the information that will help the parents understand this particular child. Many families can carry out this task by having unstructured discussions at home.

The Option of Social Transition
Families also need to know about the option of a social transition to help ease the young person’s distress and gain certainty about a transsexual identity. For a child born male but identifying as female, the social transition will generally include wearing girls’ clothes, makeup, and jewelry; letting the hair grow out; and asking others to use a chosen female name and female pronouns when referring to her. For a child born female but identifying as male, the social transition will generally include wearing boys’ clothes, using a binder to comfortably flatten the chest, and asking others to use a chosen male name and male pronouns when referring to him. 

Parents and the teen should meet with school officials to request the use of the new name and pronouns by teachers. The student will generally be the one to inform peers. The school will accommodate the student’s needs regarding gender-segregated facilities (generally a unisex bathroom and private changing area in lieu of a locker room). Parents, the teen, and school officials will discuss and address any safety concerns if a hostile or disrespectful response from peers or staff is anticipated. Part of my role is helping teens decide whether and when to initiate a social transition and helping parents get ready to support this step.

From the start, parents need confidence that I will provide a thorough and thoughtful evaluation of their child’s gender identity without any prior bias. Some parents arrive at my office with a hostile outlook and an assumption that I am a cheerleader for gender transition. By letting them know that I understand their fears and that I see my role as helping figure out what is best for their child, in most cases, I am able to move past the hostility to a collaborative effort. It is helpful to be able to describe to them a few instances in which, through discussion, a young person discovered that gender transition was not the appropriate path. If they ask, I do acknowledge that most teens who have come out to parents and others as transsexual are truly transsexual so as not to give them any false sense of the likelihood of their child having a change of heart.

Parental Fears and Concerns
There are numerous fears and concerns most parents experience when a teenager or young adult is transgender. In the case of children whose interests and behaviors did not fit social norms for their gender, parents may have already expected their child to be gay or lesbian. On hearing their child’s declaration of a transgender identity, they will tell their child that since most opportunities in life are open to all individuals, regardless of gender and sexual orientation, there is no need to make a physical transition. They will point out that while being gay or lesbian is more broadly accepted in our society, transgender people are harmed and scorned.

I emphasize to these parents that the transgender identity is not a means to accessing a specific opportunity, job, or social role, but rather it is a deeply felt sense of incongruity between one’s gender identity and one’s body, how one is perceived by others, or both. It is often helpful, in the parents’ presence, to ask the teen, “Given that we live in a society where men and women have equal access to most opportunities, where gays and lesbians are more accepted, and where it’s OK for people to have interests that are not stereotypical for their gender, why can’t you be happy just being a masculine woman or a feminine man?” The child’s answer will generally be a good starting place for the parents as they strive to understand exactly what their child means with the declaration of being transgender.

Parents of children whose interests and presentation seemed typical for their biological sex generally have a harder time grasping that their child could possibly be transgender. They are more likely to assume that some external event or internal problem has caused their child to mistakenly latch onto this idea of being transgender. Some parents believe their child is embracing a transgender identity to be rebellious, get attention, or fit in with countercultural or transgender friends.

Most teens can credibly point out to their parents that embracing transgender identity is not an easy path and not the one they would choose if their goal was simply to fit in or give their parents a hard time. If the teen has been depressed or anxious, as is the case with many transgender teens as they struggle to understand themselves, parents may believe that the transgender identity is a manifestation of mental illness. I point out that it is more likely the depression or anxiety was caused by the teen’s struggle with actual or anticipated societal disapproval because of gender identity or expression. In most cases, as teens come out, gain acceptance, and feel hopeful about a more comfortable future, their depression or anxiety will lessen or resolve entirely. When this happens, it helps parents see that their child’s affirmed gender identity is the authentic one for them. This can be an important facet of parents’ eventual support for their transgender teen or young adult.

Searching for Cause
Sometimes parents believe that the way they responded to a gender-nonconforming child has caused the child to adopt a transgender identity. One set of parents believes that by allowing their boy to play with dolls, they encouraged transgender development. The next set of parents feels that by not allowing dolls, they caused their son to rebel and choose a female identity. In a similar vein, parents may feel that if one parent was absent or was a poor role model, this caused a shift in the child’s gender identity. In fact, it is important for parents to let go of “What did I do wrong?” and move on to “What can I do right now?” and “How can I be the best support for my child at this time to help build self-confidence and self-esteem?”

Parents or other adult family members may suggest that a specific trauma or loss explains the shift in gender. They anticipate that I will then be able to process the loss or trauma with the child in therapy and undo the transgender identity or find it to be false in the first place. I certainly examine these issues in my therapy with the young person, but I also point out to the parents that most children who experience events involving trauma and loss do not become transgender. I also tell them a little about the therapy experiences of young people who reach the conclusion that they are not transgender: This does not occur by uncovering a causative factor in their past but rather by a thorough understanding of how they are feeling in the present, that their sense of gender identity is not leading toward gender transition.

Most parents start off feeling their child is too young to know with any certainty something as momentous as being transgender. This is the case whether the child is 13 years old or in his or her early 20s. Parents recall ideas they had at that age that they have long since outgrown. I generally point out to parents that gender identity is deeply felt and not something easily taken up on a whim. Teens who feel strongly that they are transsexual are highly likely to continue feeling that way in adulthood (Reed, Cohen-Kettinis, Reed, & Spack, 2008). I explain that the social transition is a fully reversible step that can help both the teen and the parents learn more about their child’s gender identity. Telling parents about the research that has been done showing low rates of posttransition regrets in adults is also helpful (de Cuypere & Veracruysse, 2009).

And some of the challenges parents face have nothing to do with whether transitioning is the right path for their teen but more to do with what the transition will mean for the parents. These include dealing with their own discomfort and shame about having a transgender child, concerns about how others will react, and feelings of loss, as many parents feel they are truly losing their girl or boy. Parents also may express anger toward their child for presenting the family with this challenge. I encourage parents to acknowledge these issues and find ways to address them on their own without burdening their child.

All parents also worry, understandably, about their transgender teenager coming to physical harm, increased harassment, or a friendless, loveless, or jobless future. I think two responses are important here. One is to acknowledge these risks but also to point out the increased risk of depression, despair, suicide attempts, self-harm, and substance abuse when a young person’s desire to understand, accept, and actualize authentic gender identity is thwarted. (The Family Acceptance Project [Ryan, 2009] has shown that parental rejection of LGBT youth correlates strongly with these risks.)

For teens and young adults whose history already includes some of these difficulties, parents can usually see improvements in these areas as the child’s gender identity is accepted. When this occurs, it helps a parent get on board with gender transition. Many parents have expressed to me how glad they are to have their happy child back, even if that child has a different gender than the one they were used to. The second response I give to parents’ fears of increased harassment is that I have seen time and again that an increase in self-esteem and self-confidence occurs when teens and young adults make a social transition or start taking hormones. More often than not, the level of harassment goes down and social acceptance goes up, leading to a greater sense of overall safety and hope for the future. When possible, it is a tremendous help for parents to meet with other parents who have shared the same fears and concerns, just as it is a great help for transgender teens to meet with their peers.

Finding Support
And what about the teen’s side of this family conflict? Teenagers are generally impatient with their parents’ ignorance, doubts, and lack of instantaneous support for gender transition. I encourage teens to take some time to fully understand themselves (and this includes meeting with me for gender identity evaluation), to stay safe and get support from peers and adults who are open minded and trustworthy, and above all to be patient with their parents and willing to collaborate with them. Teenagers and most young adults realize that the process of transitioning will go better for them in the long run if they have their parents’ support. I often point out that simply by being willing to enter into discussion and participate in therapy their parents are offering much more than many teens are able to get from their families.

Family therapy with transgender teens and their parents begins with a rift: Parents are disbelieving and focused on safety, while teens are inpatient and focused on authenticity. The goal of treatment is to arrive at a shared understanding of who the child is, what should happen next, and how to proceed with both safety and authenticity in mind.

— Irwin Krieger, LCSW, is in private practice in New Haven, CT. He is the author of Helping Your Transgender Teen: A Guide for Parents. Information about the book and an extensive listing of resources for parents of transgender teens can be found at www.helpingyourtransgenderteen.com.

References
de Cuypere, G., & Vercruysse, H., Jr. (2009). Eligibility and readiness criteria for sex reassignment surgery: Recommendations for revision of the WPATH Standards of Care. International Journal of Transgenderism, 11(3),194-205.

Reed, B.W., Cohen-Kettinis, P.T., Reed, T., & Spack, N. (2008). Medical care for gender variant young people: Dealing with the practical problems. Sexologies, 17(4), 258-264.

Ryan, C. (2009). Supportive Families, Healthy Children: Helping Families with Lesbian, Gay, Bisexual and Transgender Children. Publication of the Family Acceptance Project, San Francisco State University, CA.