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A Note On Supporting Gender Diverse Children and Young People

Some aspects of normal human diversity have historically been seen as an illness or disorder, such as homosexuality and gender non-conformance. In Australia, this is no longer the case, yet social marginalisation can still result in poor mental health. In the area of gender non-conformance, without pathologisation, mental health care no longer needs to be in the exclusive domain of specialist psychologists and psychiatrists, unless a formal diagnosis of a mental health condition is required for medical intervention. A large and growing evidence base shows that for gender-divergent children and adolescents, gender-affirming care supporting social transition results in mental health comparable to gender-conforming children and adolescents. Parts of this page may aid counsellors and psychotherapists in supporting gender-diverse children, adolescents and their families in this process.

Books and Resources to Support Trans and Gender-Diverse Children and Young People

The Rainbow Owl: https://www.the-rainbow-owl.com/ 

Binding

https://www.transhub.org.au/binding

The Binder Project (QLD & North NSW)

Graphical Resources

Trans Student Educational Resources

Gender Dysphoria

For Parents, Caregivers and Families of Transgender Children and Adolescents

Embarking on a wonderful journey of supporting your child to blossom as their authentic selves

Good to Know

Gender Diversity is Normal

A large number of human traits are seen to be different between genders. Not many would have all the stereotypical male traits or all the stereotypical female traits. We are a composite of traits which society sees as male of female and as such may fall on a spectrum of all male through a blend of both to all female. Usually these traits roughly align with our biological sex, but when they don’t, this can cause stress between who we are inside and who society thinks we are. When we know our gender doesn’t fit our sex, we may even identify as another gender or no gender at all.

Gender Dysphoria

Having a gender identity that doesn’t match our biological sex is not a disorder, but a society that assigns us a gender identity because of our biological sex which we do not relate to can cause us discomfort relating to our our assigned gender. If this discomfort is distressing enough to impact important areas of our lives or mental health, this warrant a formal diagnosis of “Gender Dysphoria” (American Psychiatric Association). This diagnosis is usually required to access medical transition, but not social transition.

Affirming your Child’s Gender Expression, including supporting their transition is best for your child’s well-being 

There are three clinical approaches which have been used with transgender children and adolescents, Reparative, Watchful waiting and Gender Affirmative [1]. The “Reparative” approach, which sees a transgender identity as pathological and undesirable and based on an incorrect assumption that gender is fully malliable. Therapy attempts to mould the child’s gender to conform to their biological sex. This is an extension of  Conversion Therapy which has been shown to be harmful, paramount to emotional abuse and is progressively being outlawed throughout the world. The “Watchful waiting” approach is based on data showing that a high number of children do not persist in their transgender identity, reverting back to their conforming gender at puberty. With this approach, children are given limited opportunities to safely explore their gender without a full social transition until they grow out of it. Reanalysis of the data showed the rate of those persisting with their transgender identity was higher than originally shown and there were predictors which indicated those more likely to persist, such as higher levels of gender dysphoria [2]. The issue with this approach is that transgender children, while waiting experience ongoing gender dysphoria. The “Gender Affirmative” approach involves working with others in the child’s environment such as parents, families and schools to affirm the transgender identities as they develop, including social transition. This is lead by the child and supported by others so as they may explore, experience and understand their gender. There is no waiting for puberty, but if puberty is soon, it may be medically delayed with the support of a pediatrician, to allow sufficient time to experience social transition. The gender affirmative approach results in mental health comparible to non-transgender children [3, 4] and significantly better than transgender children not supported by gender affirming social transition.

Law

The United Nations Office of the High Commissioner for Human Rights looked into the Human Rights Law of inclusion relating to sexual orientation and gender identity as well as practices of exclusion. Their summary is at https://www.ohchr.org/Documents/Issues/SexualOrientation/IESOGI/Reports_on_Gender_Final_Summary.pdf

In Australia court decisions have changed a number of times in recent years relating to puberty suppression and medical transition. To access puberty blocking medication from 2004-2015 court consent was required, but only parental consent after 2015. To access masculinising or feminising hormones from 2004-2017 court consent was required, but after 2017 required agreement between competent child, parents and midical team, without need for court consent. For gender affirmative surgery, such as chest and genital reconstruction, the courts have been required to give consent 2004-2017, however it is unclear after 2017 [5].

Australian Standards of Care and Treatment Guidelines For trans and gender diverse children and adolescents

The Royal Children’s Hospital in Melbourne has published in 2020 “Australian Standards of Care and Treatment Guidelines For trans and gender diverse children and adolescents version 1.3“.  These guidelines inform health practices in Australia and are an informative read for anyone involved, including parents

The Real Thing – By Brandon Kelley

“Parental love is unconditional. It transcends a person’s memory of their child. The Real Thing is an infinitely stronger bond”

Some Challenges

Mental Health

Research has shown that transgender children, adolescents and adults have poorer mental health than the general population. Research has also shown that a gender-affirmative approach from parents and key community groups supporting gender transition results in mental health outcomes comparable to the general population.

Ambiguous Loss

Ambiguous loss is where there is incomplete closure, which can extend the period of grief. Many parents and family members will attach a person’s gender to their future vision of them. When a child changes their gender, the previous gender is lost and can leave parents and other family members grieving for a part of the person who is still there. Some may say “You’ve lost a daughter but gained a son” and although this may be true, it doesn’t take away the grief of loss of gender that was part of the future hopes and vision. The loss is valid and many parents and other families experience this grief.

Desistance (De-transition)

This is when a person does not continue (persist) with their non-conforming gender choice. It may also be called de-transition or transitioning back. It is not unusual for this to happen but there is little research into the prevalence. A child or adolescent may not feel their conforming gender is the right fit for them and seek to explore other options through social transition. After some time they may feel the new gender they transitioned to isn’t the right fit either and transition back to their conforming gender or somewhere else on the gender spectrum. Some find for example that it was their sexuality that wasn’t the right fit rather than their gender after trying the new gender out. The beauty of doing this exploration pre-pubescent is that only a social transition is involved. Once gender-affirming medical transition is involved, some changes are more permanent, such as a deeper voice after taking masculinity-affirming testosterone, breast growth after taking femininity-affirming estrogen and genital reconstructive surgery. One way to mitigate this risk is to analyse the traits for signs of likely future persistence or desistence. For example, a child who says “I am a (new identity)” is more likely to persist than a child who says “I want to be a (new identity)”, but this is far from conclusive. The preferred way to mitigate the risk of desistance after making permanent changes is to affirm and support the experiential exploration of alternate genders before the onset of puberty, which in some cases will mean medically delaying puberty. Give them a chance to try before they buy
Transgender boy transitioning to life as girl changes his mind | 60 Minutes Australia

Myths

APS Refutes ‘Social Contagion’ Arguments. (Australian Psychological Society)

From The Royal Children’s Hospital

  • Young children don’t know what gender they are. FALSE
  • Allowing a child to dress as the opposite sex means they’ll become transgender. FALSE

Stories

Transgender acceptance is increasing, so some of these stories may depict circumstances such as legal aspects that have changed since the story was told.

Being Me – Four Corners. Eleven year old Isabelle’s story. (2014)

The youngest transgender child in the world | 60 Minutes Australia. Eight year old Jazz. (2009)

Inside the lives of Australian trans children | Nine News Australia.  Thirteen year old Evie. (2019)

Transgender girl’s courageous fight for acceptance | 60 Minutes Australia. Twelve year old Emma (2018)

Transgender Boy: Kai, Age 14 – Filmed for 5 years. My Genderation (2020)

Brotherboys Yarnin’ Up – Kai and Dean. Trans Health Australia (2014)

Raising Ryland: When your young daughter says ‘I’m a boy’. CNN (2015)

Resources

Information

Transgender and Gender Diverse Children. (Australian Psychological Society)

Human Rights Campaign (US)

Websites

The Rainbow Owl. Site. Books, Guides, Websites, First steps: Shared stories from parents and caregivers of trans* and gender diverse children.

Parents of Gender Diverse Children. Site. Peer support, Information resources, Australian State and Territory specific contacts and information

Transcend. Site.  Community Connection, Information resources, Australian State and Territory specific contacts and information

Research Reports

Chaplyn, G., Saunders, L. A., Lin, A., Cook, A., Winter, S., Gasson, N., … & Strauss, P. (2023). Experiences of parents of trans young people accessing Australian health services for their child: Findings from Trans Pathways. International Journal of Transgender Health, 1-17. https://doi.org/10.1080/26895269.2023.2177921

Trans Pathways. Australian study of 859 trans and gender diverse young people and views of 194 parents and guardians. Found that there was a very high risk of poor mental health including depression, anxiety, self harm and suicide attempts. They had difficulty accessing health services and many have experienced peer rejection, bullying, lack of family support and difficulties with school, university or TAFE. Webpage, Summary, Full report

LGBTIQ+ Health Australia. Snapshot of Mental Health and Suicide Prevention Statistics for LGBTIQ+ People. 2021 Statistics

References

1. Ehrensaft, D., Giammattei, S. V., Storck, K., Tishelman, A. C., & Keo-Meier, C. (2018). Prepubertal social gender transitions: What we know; what we can learn-A view from a gender affirmative lens. The International Journal of Transgenderism, 19(2), 251–268. https://doi.org/10.1080/15532739.2017.1414649

2. Steensma, T. D., McGuire, J. K., Kreukels, B. P., Beekman, A. J., & Cohen-Kettenis, P. T. (2013). Factors associated with desistence and persistence of childhood gender dysphoria: A quantitative follow-up study. Journal of the American Academy of Child and Adolescent Psychiatry, 52(6), 582–590. https://doi.org/10.1016/j.jaac.2013.03.016

3. Olson, K. R., Durwood, L., Demeules, M., & McLaughlin, K. A. (2016). Mental health of transgender children who are supported in their identities. Pediatrics (Evanston), 137(3), e20153223–e20153223. https://doi.org/10.1542/peds.2015-3223

4. Durwood, Lily, BA, McLaughlin, Katie A., PhD, & Olson, Kristina R., PhD. (2016). Mental Health and Self-Worth in Socially Transitioned Transgender Youth. Journal of the American Academy of Child and Adolescent Psychiatry, 56(2), 116–123.e2. https://doi.org/10.1016/j.jaac.2016.10.016

5. Jowett, S., & Mathews, B. (2020). Current legal and clinical framework for treatment of trans and gender diverse youth in Australia. Journal of Paediatrics and Child Health, 56(12), 1856–1860. https://doi.org/10.1111/jpc.15181

For Health Professionals

Transgender Children and Adolescents Health

Increased awareness and acceptance of gender diversity have led to an increase in trans visibility and parents of trans kids choosing a life of authenticity for their kids over distressing oppression.  This has also put pressure on the health system, which has not changed much since non-conforming gender identity was seen as a disorder, which it isn’t now. Much of what was once the domain of specialist medical practitioners and psychologists can now be managed by counsellors and psychotherapists, such as gender-affirming social transition.

Guidelines

The Royal Children’s Hospital in Melbourne has published in 2020 “Australian Standards of Care and Treatment Guidelines For trans and gender diverse children and adolescents version 1.3“.  These guidelines inform health practices in Australia

Australian Professional Association for Trans Health. Website, Standards of care

Topical

The Australian’s transgender coverage | ABC Media Watch

How this doctor made herself a ‘target’ by treating Australia’s trans kids | Australian Story | ABC News (May 2021)

Relevant Literature

Mental Health

Strauss, P., Cook, A., Winter, S., Watson, V., Wright Toussaint, D., & Lin, A. (2020). Mental Health Issues and Complex Experiences of Abuse Among Trans and Gender Diverse Young People: Findings from Trans Pathways. LGBT Health, 7(3), 128–136. https://doi.org/10.1089/lgbt.2019.0232

Strauss, P., Cook, A., Winter, S., Watson, V., Wright Toussaint, D., & Lin, A. (2020). Associations between negative life experiences and the mental health of trans and gender diverse young people in australia: Findings from Trans Pathways. Psychological Medicine, 50(5), 808–817. https://doi.org/10.1017/S0033291719000643

Minority Stress

Toomey, R. B. (2021). Advancing Research on Minority Stress and Resilience in Trans Children and Adolescents in the 21st Century. Child Development Perspectives, 15(2), 96–102. https://doi.org/10.1111/cdep.12405

Loso, H. (2021). Capturing the Experiences of Gender Non-Conforming Children Through the Minority Stress Model. UVM Scholarworks

Hatchel, T., Valido, A., De Pedro, K. T., Huang, Y., & Espelage, D. L. (2019). Minority Stress Among Transgender Adolescents: The Role of Peer Victimization, School Belonging, and Ethnicity. Journal of Child and Family Studies, 28(9), 2467–2476. https://doi.org/10.1007/s10826-018-1168-3

Gender affirming outcomes

Durwood, L., Eisner, L., Fladeboe, K., Ji, C., Barney, S., McLaughlin, K. A., & Olson, K. R. (2021). Social Support and Internalizing Psychopathology in Transgender Youth. Journal of Youth and Adolescence, 50(5), 841–854. https://doi.org/10.1007/s10964-020-01391-y

Van der Miesen, A. I., Steensma, T. D., de Vries, A. L., Bos, H., & Popma, A. (2020). Psychological Functioning in Transgender Adolescents Before and After Gender-Affirmative Care Compared With Cisgender General Population Peers. Journal of Adolescent Health, 66(6), 699–704. https://doi.org/10.1016/j.jadohealth.2019.12.018

Durwood, Lily, BA, McLaughlin, Katie A., PhD, & Olson, Kristina R., PhD. (2016). Mental Health and Self-Worth in Socially Transitioned Transgender Youth. Journal of the American Academy of Child and Adolescent Psychiatry, 56(2), 116–123.e2. https://doi.org/10.1016/j.jaac.2016.10.016

Olson, K. R., & Gülgöz, S. (2018). Early Findings From the TransYouth Project: Gender Development in Transgender Children. Child Development Perspectives, 12(2), 93–97. https://doi.org/10.1111/cdep.12268

Olson, K. R., Durwood, L., Demeules, M., & McLaughlin, K. A. (2016). Mental health of transgender children who are supported in their identities. Pediatrics (Evanston), 137(3), e20153223–e20153223. https://doi.org/10.1542/peds.2015-3223

Ehrensaft, D., Giammattei, S. V., Storck, K., Tishelman, A. C., & Keo-Meier, C. (2018). Prepubertal social gender transitions: What we know; what we can learn-A view from a gender affirmative lens. The International Journal of Transgenderism, 19(2), 251–268. https://doi.org/10.1080/15532739.2017.1414649

Working with transgender clients, families and Schools

Chaplyn, G., Saunders, L. A., Lin, A., Cook, A., Winter, S., Gasson, N., … & Strauss, P. (2023). Experiences of parents of trans young people accessing Australian health services for their child: Findings from Trans Pathways. International Journal of Transgender Health, 1-17. https://doi.org/10.1080/26895269.2023.2177921

Warner, A., Dorsen, C., Navarra, A.-M. D., & Cohen, S. (2021). An Integrative Review of Experiences Parenting Transgender and Gender Diverse Children. Journal of Family Nursing, 10748407211001559–10748407211001559. https://doi.org/10.1177/10748407211001559

Johnson, K. C., LeBlanc, A. J., Sterzing, P. R., Deardorff, J., Antin, T., & Bockting, W. O. (2020). Trans Adolescents’ Perceptions and Experiences of Their Parents’ Supportive and Rejecting Behaviors. Journal of Counseling Psychology, 67(2), 156–170. https://doi.org/10.1037/cou0000419

Wagner, L. D., & Armstrong, E. (2020). Families in Transition: The Lived Experience of Parenting a Transgender Child. Journal of Family Nursing, 26(4), 337–345. https://doi.org/10.1177/1074840720945340

Abreu, R. L., Rosenkrantz, D. E., Ryser-Oatman, J. T., Rostosky, S. S., & Riggle, E. D. B. (2019). Parental reactions to transgender and gender diverse children: A literature review. Journal of GLBT Family Studies, 15(5), 461–485. https://doi.org/10.1080/1550428X.2019.1656132

Westwater, J. J., Riley, E. A., & Peterson, G. M. (2019). What about the family in youth gender diversity? A literature review. The International Journal of Transgenderism, 20(4), 351–370. https://doi.org/10.1080/15532739.2019.1652130

Jones, T. (2017). Evidence affirming school supports for Australian transgender and gender diverse students. Sexual Health, 14(5), 412–416. https://doi.org/10.1071/SH17001

Experience of care 

Strauss, P., Lin, A., Winter, S., Waters, Z., Watson, V., Wright Toussaint, D., & Cook, A. (2021). Options and realities for trans and gender diverse young people receiving care in Australia’s mental health system: findings from Trans Pathways. Australian and New Zealand Journal of Psychiatry, 55(4), 391–399. https://doi.org/10.1177/0004867420972766

Tollit, M. A., Feldman, D., McKie, G., & Telfer, M. M. (2018). Patient and Parent Experiences of Care at a Pediatric Gender Service. Transgender Health, 3(1), 251–256. https://doi.org/10.1089/trgh.2018.0016

Legal

[Australia] Jowett, S., & Mathews, B. (2020). Current legal and clinical framework for treatment of trans and gender diverse youth in Australia. Journal of Paediatrics and Child Health, 56(12), 1856–1860. https://doi.org/10.1111/jpc.15181

Gender diversity & Neuro diversity

McPhate, L., Williams, K., Vance, A., Winther, J., Pang, K., & May, T. (2021). Gender Variance in Children and Adolescents with Neurodevelopmental and Psychiatric Conditions from Australia. Archives of Sexual Behavior, 50(3), 863–871. https://doi.org/10.1007/s10508-021-01918-9

Strauss, P., Cook, A., Watson, V., Winter, S., Whitehouse, A., Albrecht, N., Wright Toussaint, D., & Lin, A. (2021). Mental health difficulties among trans and gender diverse young people with an autism spectrum disorder (ASD): Findings from Trans Pathways. Journal of Psychiatric Research, 137, 360–367. https://doi.org/10.1016/j.jpsychires.2021.03.005

Clinician Factors

MacKinnon, K. R., Ashley, F., Kia, H., Lam, J. S. H., Krakowsky, Y., & Ross, L. E. (2021). Preventing transition “regret”: An institutional ethnography of gender-affirming medical care assessment practices in Canada. Social Science & Medicine, Volume 291, 114477.  https://doi.org/10.1016/j.socscimed.2021.114477

Journals

Transgender Health

International Journal of Transgender Health

Assessment

Parents Conditional Regard

Seager van Dyk, I., Shao, J., Sohn, L., Smiley, P. A., Olson, K. R., & Borelli, J. L. (2021). Responding to Children’s Diverse Gender Expression: Validation of a Parent-Report Measure of Gender-Related Conditional Regard. Journal of GLBT Family Studies, 1–19. https://doi.org/10.1080/1550428X.2021.1931615

Diagnostic Criteria

DSM-5: 302.6 Gender Dysphoria in Children, 302.85 Gender Dysphoria in Adolescents and Adults

ICD-11: HA61 Gender incongruence of childhood, HA60 Gender incongruence of adolescence or adulthood.

Predicting Persistence

Steensma, T. D., McGuire, Jenifer K., Ph.D., M.P.H, Kreukels, B. P. C., Beekman, Anneke J., B.Sc, & Cohen-Kettenis, P. T. (2013). Factors Associated With Desistence and Persistence of Childhood Gender Dysphoria: A Quantitative Follow-Up Study. Journal of the American Academy of Child and Adolescent Psychiatry, 52(6), 582–590. https://doi.org/10.1016/j.jaac.2013.03.016

Rae, J. R., Gülgöz, S., Durwood, L., DeMeules, M., Lowe, R., Lindquist, G., & Olson, K. R. (2019). Predicting Early-Childhood Gender Transitions. Psychological Science, 30(5), 669–681. https://doi.org/10.1177/0956797619830649

Therapy

Byrd, R., Lorelle, S., & Donald, E. (2021). Transgender and gender-expansive affirming child-centered play therapy. International Journal of Play Therapy, 30(2), 146-156. http://dx.doi.org.ezproxy.library.uq.edu.au/10.1037/pla0000155

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