Professional intervention and support for gender-variant children potentially covers a range of services from information and support for the child and the family to specialist referrals where indicated. The professional provides a place of stability within often chaotic and difficult circumstances for transgender individuals, children, and their families (Lev, 2004). These professionals are therefore exposed to the issues, concerns, and needs of gender-variant individuals and their families providing a valuable window into the needs of gender-variant children and their parents.
Until recently, the needs of gender-variant children and their parents have not been studied or documented. A number of publications (Brill & Pepper, 2008; Hill & Menvielle, 2009; Lev, 2004) and organizations have provided crucial resources and support for gender-variant children and their parents. The impact of discrimination, marginalization, and abuse on gender-variant individuals is well known (Grant et al., 2010; Nuttbrock et al., 2010; Whittle, Turner, & Al-Alami, 2007; Wyss, 2004) and begs intervention to prevent these outcomes for gender-variant children. One study (Riley, Clemson, Sitharthan, & Diamond, 2011) has explored the needs of gender-variant children and their parents via surveys of parents of gender-variant children. The authors found that the dominant children’s needs were to discuss their feelings, to be accepted, and to be allowed to express their gender, while the parent’s needs were to gain knowledge and find guidance and professional support.
The focus of this report is on the views of professionals (in clinical and other practice) of the needs of gender-variant children and their parents, drawing on years of experience of those who have direct contact with transgender persons. This is based on the principle that beneficial information can be gained from surveying those with a stake in understanding the needs of their clientele (Charmaz, 2006). This study aims to provide valuable knowledge and information to inform guidelines for the support of gender-variant children and their parents.
The term gender variance is used here to refer to gendered behavior that does not conform to prevailing gendered expectations and norms. Transgender is used here as an umbrella term to include the widest range of people with gender-variant behavior (Lev, 2004).
METHOD
Instrument
The Internet was used as a tool to recruit and survey professionals who work with the transgender community. No specification was made regarding the type of work or that the work be focused on children or families. The researchers determined that the needs of gender-variant children and their parents could be gleaned potentially from any focused work with transgender people and, therefore, chose not to limit the input to a specific type or group of professionals. The only requirement was that they serve the transgender community. An international audience was sought to provide a broad range of views and to provide a sufficient number of participants. Purposeful sampling (Charmaz, 2006; Patton, 2002) and snowballing secured participants via advertising in newspapers, magazines, radio programs, and websites and via the listserv and conference proceedings of the World Professional Association for Transgender Health. The study was approved by the University of Sydney Human Research Ethics Committee.
Procedure
Six closed-ended questions were designed to gather demographic information. Eleven open-ended questions were developed to provide the space for rich responses through which professionals could express their experience, knowledge, reflections, and ideas (Huberman & Miles, 2002; Patton, 2002). The survey allowed participants to skip questions they did not wish to answer to ensure that all responses would be voluntary. The questions initially focused on the professionals’ understandings of parents’ experiences and included questions such as, What do you understand to be the issues that parents with gender-variant children face? What do you believe creates these issues for the parents [of gender-variant children]? and What do you believe parents [of gender-variant children] want and need? The questions then attended to the children and contained the questions, What do you understand to be the issues that gender-variant children face? What do you believe creates the issues for gender-variant children? and What do you believe that gender-variant children want and need? The final series of questions targeted any concerns that professionals may have about their work with gender-variant children or their parents.
Participants
The participants were 29 professionals who identified as working with the transgender community. They included clinical practitioners (n = 22; 76%), directors/coordinators of trans-supportive organizations or programs (n = 3; 10%), educators/trainers (n = 2; 7%), one lawyer (3%), and one researcher (3%). Their demographics, training, and years’ experience in working with the transgender community are presented in Table 1.
TABLE 1. Demographic and professional practice data of participants (N = 29)
| All participants n (%) | |||
| Country | |||
| Australia | 6 (21) |
||
| Canada | 2 (7) |
||
| United Kingdom | 4 (14) |
||
| United States | 12 (41) |
||
| South Africa | 2 (7) |
||
| Finland | 1 (4) |
||
| Brazil | 1 (3) |
||
| Norway | 1 (3) |
||
29 (100) |
|||
| Qualifications (highest) | |||
| PhD | 10 (34) |
||
| Masters | 7 (24) |
||
| Graduate Diploma | 1 (3) |
||
| Bachelor | 7 (24) |
||
| Certificate | 1 (3) |
||
| No formal qualification | 3 (10) |
||
29 (100) |
* | ||
| Clinical practitioners | |||
| Counselor/Therapist | 5 (17) |
||
| Social Worker | 5 (17) |
||
| Psychologist | 6 (21) |
||
| General Practitioner | 3 (10) |
||
| Endocrinologist | 2 (7) |
||
| Gynecologist | 1 (3) |
||
22 (76) |
|||
| Other professionals | |||
| Solicitor | 1 (3) |
||
| Researcher | 1 (3) |
||
| Educator/Trainer | 2 (7) |
||
| Director/Coordinator of organization | 3 (10) |
||
7 (24) |
|||
| Total professionals | 29 (100) |
||
| Years working with transgender community | |||
| 1–5 | 9 (31) |
||
| 6–10 | 5 (17) |
||
| 11–20 | 9 (31) |
||
| > 20 | 6 (21) |
||
29 (100) |
|||
| Did you receive specialized transgender training? | |||
| Yes | 9 (31) |
||
| No | 20 (69) |
||
29 (100) |
|||
* Percentages do not add to 100 due to rounding error.
Data Analysis
The responses were examined using content analysis to identify common elements and patterns (Charmaz, 2006). Keywords were highlighted and categorized by needs, separately for gender-variant children and their parents. The identified needs were coded and placed into themes separately for children and parents.
RESULTS
Issues That Gender-Variant Children Face
Professionals reported the following issues for gender-variant children in response to the questions, What do you understand to be the issues that gender-variant children face? and What do you believe creates the issues for gender-variant children? The identified issues are grouped into categories: (a) on recognition of difference (b) due to others’ reactions, (c) due to the lack of support, and (d) concerns about the future.
On Recognition of Difference
- confusion and distress by the incongruence between the child’s gender identity and their body,
- confusion that people do not see them as they see themselves,
- fear that no one will believe them, and
- not knowing how to understand their situation or what to do
Due to Others’ Reactions
- child feeling rejected and becoming silent for fear of disappointing his or her parents;
- isolation and not having friends;
- prejudice and stigmatization; and
- bullying, threats, and physical assault that may create a fear of going to school
Due to Lack of Support
- family and interpersonal conflict created by parents’ disapproval and lack of understanding;
- lack of recognition, acknowledgment, support, or access to services;
- feeling cheated and misunderstood as their reality is denied;
- feeling bad, wrong, guilty, anxious, and ashamed, potentially leading to self-blame, a lack of self-acceptance, depression, the need for secrecy, self-hate, and suicidal ideation; and
- how to deal with demands and pressure for conformity including the lack of gender-neutral school uniforms
Concerns About the Future
- fear of adolescence or unwanted puberty
The Needs of Gender-Variant Children
Twenty-nine professionals identified a total of 94 needs of gender-variant children. These needs were grouped in the following nine themes: (a) to be accepted and supported; (b) to be heard, respected, and loved; (c) to have professional support; (d) to be allowed to express their gender; (e) to feel safe and protected; (f) to be treated and live normally; (g) to have peer contact; (h) to have school support; and (i) to have access to puberty-delaying hormones. The themes are ranked below in order of the frequency of the number of needs mentioned for each theme.
To Be Accepted and Supported (n = 18)
Acceptance and support were the most frequently cited needs for gender-variant children. Acceptance needs were described as the need for “acceptance as themselves,” “social acceptance,” “acceptance by families and friends,” “tolerance,” and, for gender-variant children, the need “to be left alone” and to have “a community who will let them be themselves.” The need for support was mentioned generally and specifically as the need to “be supported to make their own choice in their own time” and “be supported by family, friends and school to live life as they see fit.”
To Be Heard, Respected, and Loved (n = 16)
The need for children to be respected and loved included the need for “affirmation,” “to be heard and recognized,” “to be respected in their rights and decisions,” to be “heard and believed according to their inner voice regarding gender identity,” and “to be valued, heard, and
helped to live comfortably in the world.” One professional wrote that gender-variant children need to receive “love, support and acceptance regardless of the final outcome of their issues” and others that “they need to be loved as they are,” “knowing their parents will love them no matter who they become.” Time to explore was also mentioned; some professionals noted that gender-variant children need “[p]arents ... who are willing to understand them and give them time to work out their identity” and want “to be listened to, not told they will grow out of it (even though some do).”
To Have Professional Support (n = 16)
Specific suggestions were made regarding the role of medical and mental health practitioners. In particular, recommendations were made for professionals who are “understanding, knowledgeable, and educated on gender issues in childhood” and who have access to “an early recognition system” so that help can be provided as soon as possible. It was also suggested that children need “friendly,” “sensitive and proactive support from all professionals they deal with.” Additionally, professionals stated that children need “to be able to access the medical resources necessary to grow up mentally and physically healthy” and that “children need to be offered the experience of being heard and recognized in a positive atmosphere” with support towards “resolution.”
To Be Allowed to Express Their Gender (n = 10)
The need for gender-variant children to be themselves was described in a number of ways. Professionals wrote how children need to have the “acceptance, love and freedom to explore who they feel they may have been without judgement or imposition of restrictions and expectations that negatively impact who they are,” that they need to be allowed “to be themselves and dress and act any way they wish with no pressure or negative commentary,” and have “places where they can express themselves and their gender with no judgement.” Another wrote, “I think they want to be allowed to wear and do what they want, without all the constant negotiations.”
To Feel Safe and Protected (n = 8)
Professionals wrote how children need protection from “violence and discrimination ... [and] bullying” and explained that they also need the skills to deal with negativity as well as be protected from it by having access to brochures and/or booklets to help “coping with bullying and harassment.”
Respondents also wrote that children need to be “helped to live comfortably in the world,” that they had the right to “safe schools and homes,” and that “more community and school education [is needed] to sensitize the public and make things safer for Trans-inclusive families,” as well as “penalties for adults and children who commit hate crimes and/or gender-based bullying.”
To Live a Normal Life (n = 6)
There were a number of statements made about how gender-variant children need “all the same things gender-typical children need and take for granted,” including “the basic things that all children require: support, acknowledgement, protection and understanding.” Professionals also wrote that gender-variant children need “to be able to live normal lives in their affirmed gender” and need “to be able to make friends, have crushes, engage socially, without being seen as being different than other kids” while “knowing they can live successful lives” with “equal rights.” One professional explained in detail that
[gender-variant children are] no different to any other children ... it is just that children not born with GID [Gender identity disorder] receive this more easily because they are not challenging the rigid roles we somewhere along the line established in our society, about how males and females should behave and act to fit into society.
To Have Peer Contact (n = 5)
Professionals expressed “contact with similar persons” and “knowing other kids” through “peer groups” as a need for gender-variant children. One professional also wrote that “a mentor who is older and can help” would also be useful.
To Have School Support (n = 5)
Educated teachers and staff covering gender variance and diversity, with policies on bullying were identified as interventions needed for gender-variant children. In particular, professionals wrote of the need for “zero tolerance of ridicule,” for “teachers who are willing to understand,” and for “safe schools.”
To Have Access to Puberty-Delaying Hormones (n = 5)
The need for hormone blockers was stated by some professionals. Particularly for children who need them “to grow up mentally and physically healthy and avoid years of surgeries, voice training etc. that could have been prevented if unwanted puberties were stopped/prevented.” One professional wrote that “hatred for the body and changes that puberty brings” is an issue that children face if puberty-delaying hormones are not available for them. Another professional outlined in detail the physical discrepancies that children needing complete affirmation face if not provided with puberty-delaying hormones:
They will have to combat unwanted facial hair, Adam’s apple, heavy build, large hands and feet, excess height etc. for those who are MtF, And for those who are FtM, breasts, menstruation, lack of facial hair, high voice, hips, etc.
This professional further added that, if treatment is not made available,
children often have difficulty remaining in school. That stress can cause problems such as self-harm, bulimia, anorexia, sometimes depression, sometimes worse. They [the children] might get into trouble with the police or the family as they can get very angry and frustrated.
In addition to these nine themes, five needs were described that included the following: the need for children to have “gender neutral spaces,” appropriate housing, information, and resources to reduce confusion and aid in their understanding of gender variance, particularly through “more access to books and videos which would inform them about all aspects of their gender identities.” One professional cautioned that giving the children too much power may present other problems, in particular, cases in which the child uses his or her leverage of gender rights or being special as a way of negotiating out of other tasks.
Issues That Parents of Gender-Variant Children Face
Professionals identified the following issues for parents with transgender children. These issues for parents cover their initial recognition of their child’s gender variance and their lack of knowledge and available resources, the lack of support and educated professionals, their current concerns regarding their child’s health and safety and their own adjustment. These issues are listed below:
- initial disbelief, confusion, shame, and embarrassment;
- lack of understanding;
- being unsure what to do, in particular whether to support their child’s gender variance;
- not knowing where to access reliable resources and support;
- lack of acceptance by families, friend, and communities;
- uninformed medical practitioners and therapists;
- fear of making the wrong decision for their child;
- social stigma, prejudice, and pressure for their child to conform;
- schools that do not support their child;
- concern for their child’s emotional, mental, and physical health and safety; and
- the need to adjust their expectations for their child’s future.
Needs of the Parents of Gender-Variant Children
Professionals identified 98 needs for parents of gender-variant children. A significant proportion of these needs arose within themes of support, namely, emotional support—support from peers, school, society, local community, and friends and family. Other needs identified by professionals were the need for education and information; a diagnosis and treatment pathway; competent, caring professionals; and research. The themes are ranked below in order of the frequency (n) of the number of needs mentioned for each theme.
Emotional Support (n = 20)
Competent counseling/therapy was seen as a foundational need for parents where listening, reassurance, understanding, and guidance for both parents and child was recommended. Respondents felt that parents need to “know it is not their fault,” to know that it is “ok to support their child,” and to know that there are other parents dealing with similar issues and that parents should be given the time to adjust and reorient their ideas about their child’s future. Professionals also explained that parents need help with decision making and proactive support with “someone to affirm with them their child’s identity” within an “empathetic ... non-evaluative environment in which the couple can discuss their own views, opinions and feelings about how to approach raising a gender variant child.” Finally, professionals reported that parents need “guidance as to what will psychologically and physically help their children to be happy and self-assured.”
Education and Correct Information (n = 12)
Parents’ uncertainty about the facts of their child’s situation was seen as a major inhibitor to their confidence in being able to support the child. One professional wrote that “social norms relating to gender and the assumption that anatomy always matches presumed gender identity teaches parents to be upset by non-gender-conforming children.” This lack of correct information was also seen to sustain “parents own fear of what their child’s condition could mean they have done or are doing.” Another professional suggested that “if the medical system made a statement and took a position about the validity of this condition ... others may follow ... [as] people have been taught to believe what doctors say.”
Support from Society, Local Community, Friends, and Family (n = 11)
The need for support and understanding from society, neighbors, churches, and other parents as well as friends and family was noted as necessary for parents to be able to support their children publically. They cited that parents need “less social pressure to conform to rigid gender roles” with “suspension of judgement from those around [them]” and, moreover, “societal support and understanding and people to advocate for them in society.” This need for support was stressed by one professional, as “[parents] need so much support if they’re going to follow [the] child’s lead instead of pressing them to hide.”
General Support (n = 11)
This category includes the number of respondents who suggested support but gave no indication of the type of support they were referring to.
Competent, Knowledgeable Professionals (n = 10)
Educated, caring professionals and competent medical care for the child was stated as a need for parents. They wrote specifically that parents need to see professionals who have “respect for their response and the time needed to adjust [to their child’s gender]” and who “would do their best to get things right [for the child].” They also wrote that parents need professionals “who are welcoming and caring and understand [what parents are going through]” and, in particular, who are willing “to alleviate the child’s pain and distress at the effects of puberty.”
Diagnosis, Treatment, and Beneficial Outcomes for Their Children (n = 10)
The need for correct diagnosis and certainty about the recommended treatment pathways and outcomes was, according to professionals, an important concern. They felt that parents need “a clear diagnostic process” and “clear directions, and routes that will make their children’s (and their) journeys easier, not harder.” Professionals further explained that parents “need best practice medical guidelines for navigating puberty/adolescent years,” to be able “to know their child will be ok” and to “trust [that] a good life [would be available] for their child.”
Peer Support (n = 9)
Support and understanding from other parents and families with gender-variant children was stated as a need that would enable parents “to meet other families like theirs.” One professional also wrote that this would help parents know that they are not alone and provide “assistance with parenting issues.” This communication with other parents was also seen as an important form of emotional and social support, particularly in spending time with other parents “who are struggling or who have struggled with these issues.”
Support, Understanding, and Acceptance from Schools (n = 6)
Professionals had some clear ideas about what parents want and need from schools. They wrote about “schools that [need to] allow their children to be who they are with no bullying” and the need to “improve conversations at the elementary school level between kids and teachers about diversity issues,” as well as the need to educate parents “in school systems ... about sensitivity to kids who are gender variant or who may be developing GLB [gay, lesbian, or bisexual] identities” and for “more community and school education to sensitize the public and make things safer for trans-inclusive families.” Furthermore, they suggested “cross communication [between] families, medical services and schools” and that “they [parents] need a culture in which adults are much more tolerant of gender variance in elementary school where children can crossdress and play with gender roles without censure or punishment.” Additionally, they proposed that parents need “school counsellors ... [able] to help kids [who are] struggling with gender variance” and “education in elementary schools about sexuality and gender roles, gender identity and helping children develop knowledge about their own bodies.”
Research (n = 5)
Evidence-based practice was noted by some professionals as a need for parents to have confidence in recommended treatment protocols. In particular, they stated that parents need “evidence for some origin of the condition,” “more research showing the outcomes of earlier transitions,” and “verification that their child’s condition is real,” as well as a “guarantee of some right direction” for their children.
In addition to these themes, professionals mentioned other needs of parents, namely, the need for their child to be happy, the need of support for the family, and the need of legal support.
DISCUSSION
This study aimed to identify the needs of gender-variant children and their parents from the experience and perspectives of professionals who work with individuals and families seeking support for transgender issues. We have presented both what the professionals see as the issues facing these children and their parents as well as what the professionals deem to be their needs.
The issues that gender-variant children face highlight consistent deficits and negativity in the children’s lives and focus our attention to the extraordinary burden placed on gender-variant children in their formative years. A report by Grant et al. (2010) describes in detail the extraordinary levels of harassment, physical assault, and sexual violence experienced by transgender children in years during primary and high school. These issues, if unable to be alleviated, are likely to present ongoing and accumulative difficulties that then impact their lives as adults (Grant et al., 2010; Riley et al., 2011).
The needs of gender-variant children as specified by professionals (apart from the need for puberty-delaying hormones) are needs that correspond to the rights of all children. That these needs cannot be taken for granted by gender-variant children speaks volumes in terms of the lack of equality and level of discrimination enacted towards them.
The issues that parents face according to professionals suggest that the lack of knowledge and awareness about transgender people and their concerns in the general and professional community creates a vacuum leaving them with little resources and support. This adds an extra burden on parents as they have to deal with the opinions and attitudes of those around them in addition to managing their own concerns and decision making regarding their child. The needs of parents overwhelmingly feature the various types of support that would help parents become informed, be able to cope, and make the best decisions for their child. Societal and community support appear to be crucial factors for parents to comfortably engage with the tasks required of them to support their child.
This combination of issues and needs of both the children and the parents provides a window into the dearth of available resources and education that could provide much needed relief for the whole transgender community.
It may appear from the needs for gender-variant children that puberty-delaying hormones are a necessity for every child. It should be stated that gender variance in and of itself is not a reason for any child to take puberty-delaying hormones. Evaluations for puberty-delaying hormones are based on professional consultation including the assessment of the child’s level of discomfort (dysphoria) with his or her body and parental support.
Cultural variations have not been taken into account due to the small numbers of professionals in the countries represented. There simply were not enough data, partly due to the limited pool of professionals available, to take culture into consideration. Riley et al. (2011) indicated that educated professionals are in short supply even in countries where there are clinics and support services. It is likely that the needs of the children and their parents’ attitudes and ability to accept and advocate for them are related. However, the nature of this relationship cannot be discerned from our data. Future research is required to examine this relationship.
CONCLUSION
The aim of this study was to identify the needs of gender-variant children and the needs of their parents from the perspective of professionals who work with the transgender community. The study found that the issues gender-variant children and their parents face provide a stark example of the void within which parents manage the plethora of circumstances that arise when rearing a child with gender variance. This in turn appears to create an unnecessary burden on the children themselves who then may often not have much choice but to retreat into silence, isolation, conformity, and self-blame.
The needs of gender-variant children identified from the professionals’ responses revealed a lack of respect for the rights of children who experience gender variance. The most frequently mentioned needs were to be accepted and supported; to be heard, respected, and loved; to have professional support and recognition; to be allowed to express their gender; to feel safe and protected; to live a normal life; to have peer contact; to have school support and; to have access to puberty-delaying hormones. The needs of the parents focused primarily on areas of support and professional assistance, namely, the need for emotional support and guidance; education and information; support from society, local community, friends, and family; competent knowledgeable professionals; diagnosis, treatment, and beneficial outcomes for their children; peer support; support, understanding, and acceptance from schools; and research.
Together, these findings call for education programs to provide knowledge and exposure to the issues that transgender people face, across such sectors as medicine, mental health, and teaching in schools. The targeted education of medical and counseling professionals, the inclusion of printed materials in doctors’ surgeries, and the distribution of best practice guidelines and training in schools would signal a major change across the professional and community sectors that the needs of transgender children are being taken seriously.